Healthcare Provider Details

I. General information

NPI: 1851722516
Provider Name (Legal Business Name): JENNY R FLEETWOOD LMHC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W 2ND ST
BLOOMINGTON IN
47403-2209
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3450
  • Fax: 812-353-3451
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002249A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: