Provider Demographics
NPI:1265678585
Name:DURBIN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DURBIN
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 1:670 MARGARET AVENUE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3950
Mailing Address - Country:US
Mailing Address - Phone:612-225-1512
Mailing Address - Fax:
Practice Address - Street 1:670 MARGARET AVENUE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3950
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002820A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232230ZZZZMedicare UPIN