Healthcare Provider Details

I. General information

NPI: 1730425257
Provider Name (Legal Business Name): JENNIFER TARBOX BOODRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 LANTERN RD STE 125
FISHERS IN
46037-7806
US

IV. Provider business mailing address

10100 LANTERN RD STE 125
FISHERS IN
46037-7806
US

V. Phone/Fax

Practice location:
  • Phone: 317-775-3942
  • Fax: 317-775-3942
Mailing address:
  • Phone: 317-775-3942
  • Fax: 317-775-3942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042417A
License Number StateIN

VIII. Authorized Official

Name: JENNIFER TARBOX BOODRO
Title or Position: OWNER/PRESIDENT
Credential: PHD
Phone: 317-771-2077