Healthcare Provider Details

I. General information

NPI: 1912970625
Provider Name (Legal Business Name): JERELYN J. GUMERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3834 S EMERSON AVE BUILDING C, SUITE 100
INDIANAPOLIS IN
46203
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702-3299
US

V. Phone/Fax

Practice location:
  • Phone: 317-782-1577
  • Fax: 317-780-5539
Mailing address:
  • Phone: 775-222-0044
  • Fax: 888-700-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number71000562A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number71000562A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000562A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: