Provider Demographics
NPI:1104074830
Name:SPRAKER, JENNIFER KAY (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:SPRAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7639 BAYVIEW CLUB DR APT 3C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N 16TH ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4319
Practice Address - Country:US
Practice Address - Phone:765-521-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-06
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99034126A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016276Medicaid