Provider Demographics
NPI:1134897242
Name:EBEY, JESSICA RAE (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:EBEY
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 1:304 E VISTULA ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-9489
Mailing Address - Country:US
Mailing Address - Phone:574-848-4039
Mailing Address - Fax:
Practice Address - Street 1:304 E VISTULA ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:IN
Practice Address - Zip Code:46507-9489
Practice Address - Country:US
Practice Address - Phone:574-848-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011888A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300057089Medicaid