Healthcare Provider Details

I. General information

NPI: 1487612131
Provider Name (Legal Business Name): JACQUELYN CORNISH LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SOUTHFIELD DR
PLAINFIELD IN
46168-2464
US

IV. Provider business mailing address

PO BOX 4323
TERRE HAUTE IN
47804-0323
US

V. Phone/Fax

Practice location:
  • Phone: 317-837-9719
  • Fax: 317-837-9726
Mailing address:
  • Phone: 812-231-8323
  • Fax: 812-231-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001426
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: