Basic Information
| Provider Information | |||||||||
| NPI: | 1083634141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOUTS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E. 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984449 | ||||||||
| FaxNumber: | 7652984950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1629 MEDICAL ARTS BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652985439 | ||||||||
| FaxNumber: | 7652984920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71000945A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200352830 | 05 | IN | MEDICAID |