Provider Demographics
NPI:1780758474
Name:JODWAY, TERESA LYNNE (CPNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNNE
Last Name:JODWAY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11983 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-7817
Mailing Address - Country:US
Mailing Address - Phone:574-259-6836
Mailing Address - Fax:
Practice Address - Street 1:209 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8048
Practice Address - Country:US
Practice Address - Phone:574-246-1000
Practice Address - Fax:574-246-4000
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000447A363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28103938AOtherRN LICENSE
IN200204520Medicaid
IN71000447AOtherNP LICENSE
IN71000447AOtherNP LICENSE