Provider Demographics
NPI:1437711785
Name:COFFEEN, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:COFFEEN
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 1:1405 FARRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5975
Mailing Address - Country:US
Mailing Address - Phone:219-575-0786
Mailing Address - Fax:
Practice Address - Street 1:604 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5268
Practice Address - Country:US
Practice Address - Phone:219-362-8761
Practice Address - Fax:219-362-9157
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013129A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation