Basic Information
| Provider Information | |||||||||
| NPI: | 1568428019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKMAN-CHUPPE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LACKMAN-CHUPPE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3371 CLEVELAND ROAD EXT | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466289780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742712558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746477459 | ||||||||
| FaxNumber: | 5746473658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01037290 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930101010 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 000000181682 | 01 | IN | ANTHEM | OTHER | 104340074 | 05 | MI | MEDICAID | 100091200 | 05 | IN | MEDICAID |