Provider Demographics
NPI:1487646469
Name:CHAMBERS, JODI L (PA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:260-266-4007
Practice Address - Fax:260-266-4008
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000487A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970018667OtherRAIL ROAD MEDICARE
IN300006248Medicaid
IN058940MMMedicare ID - Type Unspecified
IN970018667OtherRAIL ROAD MEDICARE
INP25599Medicare UPIN