Healthcare Provider Details

I. General information

NPI: 1982632329
Provider Name (Legal Business Name): JEFFREY T FEATHERGILL PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W WASHINGTON ST STE 2311
SOUTH BEND IN
46601-1708
US

IV. Provider business mailing address

211 W WASHINGTON ST STE 2311
SOUTH BEND IN
46601-1708
US

V. Phone/Fax

Practice location:
  • Phone: 574-282-1090
  • Fax: 866-540-3094
Mailing address:
  • Phone: 574-282-1090
  • Fax: 866-540-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20041616A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number20041616A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041616A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041616A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: