Basic Information
| Provider Information | |||||||||
| NPI: | 1669447900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULT | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | |||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15900 W 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463113065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656333 | ||||||||
| FaxNumber: | 2193658291 | ||||||||
| Practice Location | |||||||||
| Address1: | 15900 W 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463113065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656333 | ||||||||
| FaxNumber: | 2193658291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 071004325A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 200424880A | 05 | IN | MEDICAID |