Provider Demographics
NPI:1497412571
Name:BOSAK, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOSAK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BUSSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:31 SIBLEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46320-1725
Mailing Address - Country:US
Mailing Address - Phone:219-802-8800
Mailing Address - Fax:
Practice Address - Street 1:31 SIBLEY ST STE A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1725
Practice Address - Country:US
Practice Address - Phone:219-802-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28229924A163W00000X
IN71012008A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse