Provider Demographics
NPI:1083008494
Name:GREENWALD, JACQUILINE N (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUILINE
Middle Name:N
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 E SOUTHPORT RD STE 800
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-3265
Mailing Address - Country:US
Mailing Address - Phone:131-780-9375
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:3830 E SOUTHPORT RD STE 800
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3265
Practice Address - Country:US
Practice Address - Phone:317-809-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005524A363LA2200X
FLAPRN9483846363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201293510Medicaid
FL100277200Medicaid
IN201293510Medicaid