Basic Information
| Provider Information | |||||||||
| NPI: | 1962462804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWAN | ||||||||
| FirstName: | JACQUELYNN | ||||||||
| MiddleName: | THERESE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAAVEDRA | ||||||||
| OtherFirstName: | JACQUELYNN | ||||||||
| OtherMiddleName: | THERESE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5492 N RONALD REAGAN PKWY STE 260 | ||||||||
| Address2: | |||||||||
| City: | BROWNSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461125618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174569053 | ||||||||
| FaxNumber: | 3173865480 | ||||||||
| Practice Location | |||||||||
| Address1: | 5492 N RONALD REAGAN PKWY STE 260 | ||||||||
| Address2: | |||||||||
| City: | BROWNSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461125618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172172444 | ||||||||
| FaxNumber: | 3172172449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01064739A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 354590084 | 01 | IN | MEDICARE | OTHER | 200907780 | 05 | IN | MEDICAID |