Provider Demographics
NPI:1588014914
Name:MCCUDDY, JEANNA (NP-C)
Entity Type:Individual
Prefix:MS
First Name:JEANNA
Middle Name:
Last Name:MCCUDDY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:JEANNA
Other - Middle Name:MARIE
Other - Last Name:GEDDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:547-647-1840
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:STE 4440
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-5300
Practice Address - Fax:574-647-5305
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006368A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201372590Medicaid
IN236040263OtherMEDICARE PTAN
IN247000023OtherMEDICARE PTAN
IN169380071OtherMEDICARE PTAN
IN231860008OtherMEDICARE PTAN
IN201372590Medicaid