Provider Demographics
NPI:1396189056
Name:HORAN, JESSICA LUCILLE (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LUCILLE
Last Name:HORAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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 1:699 RILEY HOSPITAL DR
Practice Address - Street 2:ROOM RR 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5119
Practice Address - Country:US
Practice Address - Phone:317-274-4715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3227208000000X
IN02004849A2080N0001X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201372870Medicaid