Provider Demographics
NPI:1033345822
Name:NTI, JACQUELINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:NTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:S
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
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:317-621-9312
Mailing Address - Fax:317-621-6920
Practice Address - Street 1:7910 E WASHINGTON ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6803
Practice Address - Country:US
Practice Address - Phone:317-355-5437
Practice Address - Fax:317-355-9047
Is Sole Proprietor?:No
Enumeration Date:2009-06-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47602208000000X
IN01071071208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201069230Medicaid
IN201069230Medicaid