Provider Demographics
NPI:1457096935
Name:MARKULIN, JAMIE M (AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:M
Last Name:MARKULIN
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:9120 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2907
Practice Address - Country:US
Practice Address - Phone:219-703-5301
Practice Address - Fax:219-703-6718
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012539A364SG0600X
IN28204648A364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300061751Medicaid