Provider Demographics
NPI:1316611361
Name:MICHAELIS, JEREMY (NP-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 STURDY RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4126
Mailing Address - Country:US
Mailing Address - Phone:219-462-7173
Mailing Address - Fax:
Practice Address - Street 1:2323 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312
Practice Address - Country:US
Practice Address - Phone:219-354-8910
Practice Address - Fax:219-354-0900
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011400A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner