Provider Demographics
NPI:1356445878
Name:CROCKER, JENNIFER V (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:V
Last Name:CROCKER
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:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:702 BARNHILL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5128
Practice Address - Country:US
Practice Address - Phone:317-274-1201
Practice Address - Fax:317-278-9905
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010578652081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200446960Medicaid
KY64066848Medicaid
H66703Medicare UPIN
145590H3Medicare ID - Type Unspecified