Provider Demographics
NPI:1356449664
Name:LOCKLIEAR, JENNIFER ANN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:LOCKLIEAR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 E STOP 11 RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-6340
Mailing Address - Country:US
Mailing Address - Phone:317-851-2331
Mailing Address - Fax:317-851-2333
Practice Address - Street 1:5255 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6340
Practice Address - Country:US
Practice Address - Phone:317-851-2331
Practice Address - Fax:317-851-2333
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN248030DMedicare PIN