1750752853 NPI number — JENNIFER L. COUNCELLER NP

Table of content: JENNIFER L. COUNCELLER NP (NPI 1750752853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750752853 NPI number — JENNIFER L. COUNCELLER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUNCELLER
Provider First Name:
JENNIFER
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1750752853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 REID PKWY
Provider Second Line Business Mailing Address:
MEDICAL STAFF SERVICES
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47374-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-825-8446
Provider Business Mailing Address Fax Number:
765-827-0013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1473 E STATE ROAD 44
Provider Second Line Business Practice Location Address:
WHITEWATER VALLEY PRIMARY CARE
Provider Business Practice Location Address City Name:
CONNERSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47331-8374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-825-8446
Provider Business Practice Location Address Fax Number:
765-827-0013
Provider Enumeration Date:
10/14/2015

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: 363LF0000X , with the licence number:  71005873A , 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: 201325910 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0150521 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000965537 . This is a "ANTHEM (REID PHYSICIAN ASSOCIATES, INC.)" identifier . This identifiers is of the category "OTHER".