Healthcare Provider Details

I. General information

NPI: 1154917094
Provider Name (Legal Business Name): JGWHARTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 E MAIN ST
AVON IN
46123-9174
US

IV. Provider business mailing address

4265 E MAIN ST
AVON IN
46123-9174
US

V. Phone/Fax

Practice location:
  • Phone: 317-268-6555
  • Fax: 317-268-6556
Mailing address:
  • Phone: 317-268-6555
  • Fax: 317-268-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: RITA BEDWELL
Title or Position: DELEGATED OFFICAL
Credential:
Phone: 317-268-6555