Provider Demographics
NPI:1144229295
Name:HIAM, JENNIE P
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:P
Last Name:HIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 JOHN ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-2705
Mailing Address - Country:US
Mailing Address - Phone:812-421-7489
Mailing Address - Fax:812-421-7494
Practice Address - Street 1:907 SE 8TH ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1530
Practice Address - Country:US
Practice Address - Phone:812-436-0224
Practice Address - Fax:812-436-0230
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000328971OtherANTHEM BC/BS
IN100465880AMedicaid
IN351791786104OtherCARESOURCE PROVIDER ID
IN637650JMedicare ID - Type Unspecified
IN351791786104OtherCARESOURCE PROVIDER ID