Provider Demographics
NPI:1932669306
Name:DEIS, JESSICA WREN (CNM)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:WREN
Last Name:DEIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MCGRATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-8231
Practice Address - Fax:317-948-7900
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY367A00000X
MDR241288367A00000X
IN09000401C367A00000X
KY3014953363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid