Provider Demographics
NPI:1265492599
Name:STEVENS, JACQUELINE M (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:CHAPPELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7916 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-434-6339
Mailing Address - Fax:260-434-6389
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6420
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200250820Medicaid
IN000000345345OtherANTHEM
IN260690KKKMedicare PIN
INQ31957Medicare UPIN
IN200250820Medicaid
IN000000345345OtherANTHEM