Healthcare Provider Details

I. General information

NPI: 1528539533
Provider Name (Legal Business Name): KALYN JORGENSEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 INTECH BLVD STE 195
INDIANAPOLIS IN
46278-2014
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-295-0608
  • Fax:
Mailing address:
  • Phone: 317-963-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003414A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: