Provider Demographics
NPI:1962462804
Name:SWAN, JACQUELYNN THERESE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:THERESE
Last Name:SWAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYNN
Other - Middle Name:THERESE
Other - Last Name:SAAVEDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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 1:5492 N RONALD REAGAN PKWY STE 260
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-5618
Practice Address - Country:US
Practice Address - Phone:317-217-2444
Practice Address - Fax:317-217-2449
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064739A207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1100217272OtherANTHEM PTAN
IN200907780Medicaid
IN200907780Medicaid
FL07128SMedicare PIN
FL048307900Medicaid