Basic Information
| Provider Information | |||||||||
| NPI: | 1710275011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 S EAST ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462277107 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1542 S BLOOMINGTON ST | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461352212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653017449 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2011 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.