Healthcare Provider Details

I. General information

NPI: 1073398186
Provider Name (Legal Business Name): AXON COLUMBUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 FOX POINTE DR STE B
COLUMBUS IN
47203-3391
US

IV. Provider business mailing address

9245 N MERIDIAN ST STE 300
INDIANAPOLIS IN
46260-1832
US

V. Phone/Fax

Practice location:
  • Phone: 812-665-0181
  • Fax: 812-605-0183
Mailing address:
  • Phone: 317-818-9000
  • Fax: 317-818-9009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: JERAD DALTON
Title or Position: MEMBER
Credential: DO
Phone: 317-402-8992