Provider Demographics
NPI:1144279720
Name:JEDELE, CHERRYL ANN I
Entity type:Individual
Prefix:MS
First Name:CHERRYL
Middle Name:ANN
Last Name:JEDELE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ST RD 67 S
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158
Mailing Address - Country:US
Mailing Address - Phone:317-831-3220
Mailing Address - Fax:317-931-3321
Practice Address - Street 1:625 ST RD 67 S
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1710
Practice Address - Country:US
Practice Address - Phone:317-831-3221
Practice Address - Fax:317-831-3321
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17440000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5730850001Medicare NSC