Provider Demographics
NPI:1174511356
Name:JENISON, JAMES E (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:JENISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W BUENA VISTA RD
Mailing Address - Street 2:STE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-5185
Mailing Address - Country:US
Mailing Address - Phone:812-485-1220
Mailing Address - Fax:812-485-8544
Practice Address - Street 1:1202 W BUENA VISTA RD
Practice Address - Street 2:STE 102
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-5185
Practice Address - Country:US
Practice Address - Phone:812-425-0300
Practice Address - Fax:812-428-8400
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035567A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100248070AMedicaid
1578786612OtherGROUP NPI
000000637987OtherANTHEM PIN
IN200859330QOtherMEDICAID GROUP
C25884Medicare UPIN
IN200859330QOtherMEDICAID GROUP
IN250470FFMedicare PIN