Basic Information
| Provider Information | |||||||||
| NPI: | 1154586030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTWELL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123765315 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 NORTH MARR ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123769219 | ||||||||
| FaxNumber: | 8123784821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01069351A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201027470 | 05 | IN | MEDICAID | 000000984526 | 01 | ANTHEM PIN | OTHER |