Healthcare Provider Details

I. General information

NPI: 1043260094
Provider Name (Legal Business Name): JENNIFER R PEVERLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N ENGLEWOOD DR
CRAWFORDSVILLE IN
47933-9744
US

IV. Provider business mailing address

1450 W 800 S
COVINGTON IN
47932-8033
US

V. Phone/Fax

Practice location:
  • Phone: 765-361-9767
  • Fax: 765-361-0374
Mailing address:
  • Phone: 765-397-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004893A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: