Provider Demographics
NPI:1750651188
Name:BRONNER, JESSICA SOPHIA (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SOPHIA
Last Name:BRONNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1225 E COOLSPRING AVE STE 2B
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-878-5029
Practice Address - Fax:219-878-8493
Is Sole Proprietor?:No
Enumeration Date:2012-01-02
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003880A363LF0000X
IN28142364A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201068100Medicaid