Provider Demographics
NPI:1063735595
Name:DAVIS, JENNIFER ELAINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:CROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-3000
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003190A363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430H68OtherMEDICARE PTAN
IN300051234Medicaid
IN267030319OtherMEDICARE PTAN