Provider Demographics
NPI:1043854409
Name:TANK, JACKIE SUZANNE (PA)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SUZANNE
Last Name:TANK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:REUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5255 E STOP 11 RD STE 204
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6341
Practice Address - Country:US
Practice Address - Phone:317-528-2555
Practice Address - Fax:317-528-2566
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10002853A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant