Basic Information
| Provider Information | |||||||||
| NPI: | 1144596628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROIX | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 S. NEW ST. | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61820 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1633 N CAPITOL AVE STE 640 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628881 | ||||||||
| FaxNumber: | 3179620838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 08/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207N00000X | 284898 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.