Healthcare Provider Details

I. General information

NPI: 1346160355
Provider Name (Legal Business Name): JENNIFER L STAAB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S WALNUT ST STE 11
BLOOMINGTON IN
47404-6118
US

IV. Provider business mailing address

394 FREEMAN RIDGE RD
NASHVILLE IN
47448-8871
US

V. Phone/Fax

Practice location:
  • Phone: 812-731-4736
  • Fax:
Mailing address:
  • Phone: 812-606-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005990A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: