Healthcare Provider Details

I. General information

NPI: 1992531503
Provider Name (Legal Business Name): JEREMY MABIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 ROSLIN RD
NEWBURGH IN
47630-8590
US

IV. Provider business mailing address

1920 E GUM ST
EVANSVILLE IN
47714-2114
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-7200
  • Fax:
Mailing address:
  • Phone: 812-454-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71015737A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: