1619048246 NPI number — MRS. JENNIFER ANN CURTIS MSW LCSW

Table of content: MRS. JENNIFER ANN CURTIS MSW LCSW (NPI 1619048246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619048246 NPI number — MRS. JENNIFER ANN CURTIS MSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CURTIS
Provider First Name:
JENNIFER
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LILLICH
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619048246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 LINCOLNWAY E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46544-2016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-255-4976
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 RED COACH DR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-8324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-7630
Provider Business Practice Location Address Fax Number:
574-335-0841
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34005049A , 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: 300044931 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 79521800 . This is a "MAGELLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000341298 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000530304 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000851241 . This is a "BCBS BMG BEHAVIORAL HEALTH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000001342255 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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