Individual
JACKIE DEAN VANNATTA JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2525 LAKE AVE, FORT WAYNE, IN 46805-5407
(260) 484-4153
Mailing address
2525 LAKE AVE, FORT WAYNE, IN 46805-5407
(260) 484-4153
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
08/24/2018
Last updated
08/24/2018
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