Provider Demographics
NPI:1861663510
Name:JOSEPH, JODY (FNP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:FNP
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:574-472-6700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:2349 LAKE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7836
Practice Address - Country:US
Practice Address - Phone:574-472-6700
Practice Address - Fax:574-941-3112
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002470A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000726441OtherBCBS
IN200893890Medicaid
IN000000726441OtherBCBS
IN000000562397OtherANTHEM, BCBS
IN000000562397OtherANTHEM, BCBS
INP01192731Medicare PIN
IN000000726441OtherBCBS