Individual
JESSE R KOOISTRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP
Contact information
Practice address
1500 PROVIDENT DR STE A, WARSAW, IN 46580-3297
(574) 372-7637
Mailing address
6920 POINTE INVERNESS WAY STE 200, FORT WAYNE, IN 46804-7934
(260) 479-3513
Taxonomy
Speciality
Code
Description
License number
State
146N00000X
Basic Emergency Medical Technician
—
—
163WE0003X
Emergency Registered Nurse
E3105472
IN
363LF0000X
Family Nurse Practitioner
Primary
71016732A
IN
363LF0000X
Family Nurse Practitioner
E3105472
IN
Other
Enumeration date
03/11/2025
Last updated
07/18/2025
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