Provider Demographics
NPI:1598327009
Name:CHITENJE, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CHITENJE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13914 BOULDER CANYON DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5361
Mailing Address - Country:US
Mailing Address - Phone:574-210-9966
Mailing Address - Fax:
Practice Address - Street 1:13914 BOULDER CANYON DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-5361
Practice Address - Country:US
Practice Address - Phone:574-210-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology