Provider Demographics
NPI:1134213168
Name:FRASURE, JENNIFER R (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:FRASURE
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 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:104 E CULVER RD STE 102
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2241
Practice Address - Country:US
Practice Address - Phone:574-772-7918
Practice Address - Fax:574-772-0894
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200466520FMedicaid
IN151020IIMedicare PIN
Q15638Medicare UPIN