Provider Demographics
NPI:1184616179
Name:TOBIN, JENNIFER L (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TOBIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:PURDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-482-5060
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003806363A00000X
IN10000730A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00273348OtherRAIL ROAD MEDICARE
IN058940MMMMedicaid
INQ32982Medicare UPIN
INP00273348Medicare PIN
IN058940MMMMedicare ID - Type Unspecified