Provider Demographics
NPI:1295755684
Name:SWENBERG, JESSICA L (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SWENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
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 1:55 BRENDON WAY
Practice Address - Street 2:SUITE 800
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1955
Practice Address - Country:US
Practice Address - Phone:317-777-6400
Practice Address - Fax:317-777-6410
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052923A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000313041OtherANTHEM
IN201155110Medicaid
INP00116645OtherRR MEDICARE
IN215140DMedicare PIN
IN201155110Medicaid
INP01202283Medicare PIN
INH76098Medicare UPIN
INP00116645OtherRR MEDICARE