Provider Demographics
NPI:1740374826
Name:RICHARDSON, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1020
Mailing Address - Country:US
Mailing Address - Phone:812-634-7726
Mailing Address - Fax:812-634-7625
Practice Address - Street 1:3404 NEWTON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1020
Practice Address - Country:US
Practice Address - Phone:812-634-7726
Practice Address - Fax:812-634-7625
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047337A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200227510Medicaid
ING96815Medicare UPIN
232930AMedicare PIN