Provider Demographics
NPI:1568428019
Name:LACKMAN-CHUPPE, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LACKMAN-CHUPPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:LACKMAN-CHUPPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3371 CLEVELAND ROAD EXT
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9780
Mailing Address - Country:US
Mailing Address - Phone:574-271-2558
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1087
Practice Address - Country:US
Practice Address - Phone:574-647-7459
Practice Address - Fax:574-647-3658
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037290207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN930101010OtherRAIL ROAD MEDICARE
IN000000181682OtherANTHEM
MI104340074Medicaid
IN100091200Medicaid
IN176490EMedicare ID - Type Unspecified
IN100091200Medicaid