Healthcare Provider Details

I. General information

NPI: 1962015453
Provider Name (Legal Business Name): JARED RENSBERGER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 38TH ST
MARION IN
46953-4568
US

IV. Provider business mailing address

1700 E 38TH ST
MARION IN
46953-4568
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-3321
  • Fax:
Mailing address:
  • Phone: 765-674-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3797-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: