Provider Demographics
NPI:1538715842
Name:DETWEILER, JENNIFER MARIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DETWEILER
Suffix:
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 1:1501 E EATON WHEELING PIKE
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:IN
Mailing Address - Zip Code:47338-8912
Mailing Address - Country:US
Mailing Address - Phone:765-993-3834
Mailing Address - Fax:
Practice Address - Street 1:3400 E STATE ROAD 28
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-9799
Practice Address - Country:US
Practice Address - Phone:765-288-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000917A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer