Provider Demographics
NPI:1063781532
Name:EVANS, JENNIFER (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 FRANKLIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3411
Mailing Address - Country:US
Mailing Address - Phone:317-449-9669
Mailing Address - Fax:888-915-0644
Practice Address - Street 1:613 FRANKLIN ST STE C
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3411
Practice Address - Country:US
Practice Address - Phone:317-449-9669
Practice Address - Fax:888-915-0644
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28145112A163W00000X
IN71003874A363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201067810Medicaid