Individual
JAMIE THACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4630 VISTULA RD, MISHAWAKA, IN 46544-4000
(574) 647-1900
(574) 647-7289
Mailing address
3245 HEALTH DR STE 100, GRANGER, IN 46530-1380
(574) 647-2129
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
28202077A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300083152
—
IN
Enumeration date
08/11/2022
Last updated
11/30/2023
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