Basic Information
| Provider Information | |||||||||
| NPI: | 1487080644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SPARKS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 MEDICAL ARTS BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460113458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652985280 | ||||||||
| FaxNumber: | 7652985279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71004639A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SA2200X | 71004639A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 201191150 | 05 | IN | MEDICAID | P01456903 | 01 | IN | RR MEDICARE | OTHER |