Provider Demographics
NPI:1134129919
Name:CORBAN, JENA M (MSN)
Entity Type:Individual
Prefix:MS
First Name:JENA
Middle Name:M
Last Name:CORBAN
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 E DAY RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3444
Mailing Address - Country:US
Mailing Address - Phone:574-231-6190
Mailing Address - Fax:574-247-1012
Practice Address - Street 1:270 E DAY RD
Practice Address - Street 2:SUITE 280
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3444
Practice Address - Country:US
Practice Address - Phone:574-231-6190
Practice Address - Fax:574-247-1012
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7100148A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200413370AMedicaid
INP77019Medicare UPIN
IN200413370AMedicaid