Healthcare Provider Details

I. General information

NPI: 1649589292
Provider Name (Legal Business Name): JENNIFER CHADWICK LMHC, CSAYC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 DECATUR BLVD
INDIANAPOLIS IN
46241-9534
US

IV. Provider business mailing address

6067 DECATUR BLVD
INDIANAPOLIS IN
46241-9606
US

V. Phone/Fax

Practice location:
  • Phone: 317-455-7245
  • Fax: 317-455-7276
Mailing address:
  • Phone: 317-856-5201
  • Fax: 317-856-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001220A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: