Provider Demographics
NPI:1730378555
Name:MANN, JESSICA (PNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-7728
Practice Address - Fax:317-274-2940
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010002603363LP0222X
IN71013410A363LP0200X
NY590657-1363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN074790137OtherMEDICARE