Provider Demographics
NPI:1982956017
Name:DECAVITCH, JEAN MARIE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:MARIE
Last Name:DECAVITCH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:SWENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:6831 W 133RD AVE
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-8989
Practice Address - Country:US
Practice Address - Phone:219-374-5970
Practice Address - Fax:219-374-7505
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-13
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28125157A363LF0000X
IN71004201A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201129930Medicaid
IN201129930Medicaid