Basic Information
| Provider Information | |||||||||
| NPI: | 1356344766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTAK | ||||||||
| FirstName: | JENELLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MYRES - JUSTAK | ||||||||
| OtherFirstName: | JENELLE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128535300 | ||||||||
| FaxNumber: | 8128584660 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128535300 | ||||||||
| FaxNumber: | 8128584660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 02002672A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200453490 | 05 | IN | MEDICAID | 000000305337 | 01 | IN | BCBS PIN | OTHER |