Provider Demographics
NPI:1780815100
Name:EVELAND, JACQUELINE ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:EVELAND
Suffix:
Gender:F
Credentials:NP
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 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:209 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1861
Practice Address - Country:US
Practice Address - Phone:574-941-3111
Practice Address - Fax:574-335-0745
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28130507A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000660693OtherBCBS
IN000000660693OtherBCBS
INP01207571Medicare PIN