Basic Information
| Provider Information | |||||||||
| NPI: | 1497243802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENMAN | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | CAROLINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMPSHIRE | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | CAROLINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| 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: | 05/01/2018 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208100000X | 01088005A | IN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.