Provider Demographics
NPI:1316122484
Name:FORTUNAK, JESSICA H (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:FORTUNAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7520
Mailing Address - Fax:317-806-1112
Practice Address - Street 1:9669 E 146TH ST STE 250
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-5006
Practice Address - Country:US
Practice Address - Phone:317-621-9926
Practice Address - Fax:317-621-9677
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002547A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002547AOtherNP LICENSE #
IN200882800Medicaid