Provider Demographics
NPI:1407179443
Name:PIKE, JENNIE L (NP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:PIKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:JENNIE
Other - Middle Name:L
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
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:ROC 4340
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5128
Practice Address - Country:US
Practice Address - Phone:317-274-5611
Practice Address - Fax:317-274-3107
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28071900363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200291240Medicaid