Basic Information
| Provider Information | |||||||||
| NPI: | 1598250797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRISTOW | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | ALLISON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9615 E 148TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460604371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175870500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2506 WILLOWBROOK PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175741254 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 28202301A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.