Basic Information
| Provider Information | |||||||||
| NPI: | 1457096935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARKULIN | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | AGCNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 9120 COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197035301 | ||||||||
| FaxNumber: | 2197036718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2022 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SG0600X | 71012539A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 364SG0600X | 28204648A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 300061751 | 05 | IN | MEDICAID |