Individual
JENNIFER L. LACKMAN-CHUPPE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
615 N MICHIGAN ST, SOUTH BEND, IN 46601-1087
(574) 647-7459
(574) 647-3658
Mailing address
3371 CLEVELAND ROAD EXT, SUITE 210, SOUTH BEND, IN 46628-9780
(574) 271-2558
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
01037290
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000181682
ANTHEM
IN
05
—
100091200
—
IN
05
—
104340074
—
MI
01
—
930101010
RAIL ROAD MEDICARE
IN
Enumeration date
04/25/2006
Last updated
12/12/2018
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