Provider Demographics
NPI:1093213753
Name:MERTL, JENNIFER ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:MERTL
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
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 1:1640 CRAWFORDSVILLE SQUARE DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3800
Practice Address - Country:US
Practice Address - Phone:765-362-5789
Practice Address - Fax:765-362-2453
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71008217A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300018651Medicaid
INM147140142OtherMEDICARE PTAN