Provider Demographics
NPI:1114900974
Name:STANLEY, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 HENRY ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1030
Practice Address - Country:US
Practice Address - Phone:812-352-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051065A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200173960Medicaid
INP00714997OtherRAILROAD INDIVIDUAL
INDC3600OtherRAILROAD GROUP
INM400070157Medicare PIN
IN178730GMedicare PIN
IN255510DMedicare PIN
INP00714997OtherRAILROAD INDIVIDUAL