Provider Demographics
NPI:1720567167
Name:MARREN, JEANA MARIE
Entity Type:Individual
Prefix:DR
First Name:JEANA
Middle Name:MARIE
Last Name:MARREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 GLADEWOOD DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-8908
Mailing Address - Country:US
Mailing Address - Phone:269-635-2752
Mailing Address - Fax:
Practice Address - Street 1:1005 N HICKORY RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2280
Practice Address - Country:US
Practice Address - Phone:574-233-5754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012968A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist