Healthcare Provider Details

I. General information

NPI: 1356838064
Provider Name (Legal Business Name): JENNIFER SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 ALLISONVILLE RD STE 190
FISHERS IN
46038-1862
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-678-3850
  • Fax: 317-968-1142
Mailing address:
  • Phone: 317-678-3850
  • Fax: 317-968-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number20042826A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: