Provider Demographics
NPI:1447971346
Name:SUMPTER, JACQUELINE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:SUMPTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4542
Mailing Address - Country:US
Mailing Address - Phone:219-682-6266
Mailing Address - Fax:
Practice Address - Street 1:8500 BROADWAY STE H
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7006
Practice Address - Country:US
Practice Address - Phone:219-769-7758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27054773A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse