Basic Information
| Provider Information | |||||||||
| NPI: | 1316122484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTUNAK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217520 | ||||||||
| FaxNumber: | 3178061112 | ||||||||
| Practice Location | |||||||||
| Address1: | 9669 E 146TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460605006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219926 | ||||||||
| FaxNumber: | 3176219677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| 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 | 363LP0200X | 71002547A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 71002547A | 01 | IN | NP LICENSE # | OTHER | 200882800 | 05 | IN | MEDICAID |