Provider Demographics
NPI:1225032642
Name:LANDRIGAN, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:LANDRIGAN
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 1:7910 W JEFFERSON BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-3789
Mailing Address - Fax:260-436-2703
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:STE 201
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-436-3789
Practice Address - Fax:260-436-2703
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044734A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200130020Medicaid
225950FMedicare PIN