1568739910 NPI number — JED MENTAL HEALTH PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568739910 NPI number — JED MENTAL HEALTH PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JED MENTAL HEALTH PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568739910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
192 N STATE ROAD 267
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46123-9513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-672-6400
Provider Business Mailing Address Fax Number:
317-672-6401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
192 N STATE ROAD 267
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46123-9513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-672-6400
Provider Business Practice Location Address Fax Number:
317-672-6400
Provider Enumeration Date:
11/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DINUNZIO
Authorized Official First Name:
JANE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-672-6400

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  34005048A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: M100060443 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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