Healthcare Provider Details

I. General information

NPI: 1891464061
Provider Name (Legal Business Name): JAELYN FENNELL M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 06/10/2024
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S US HIGHWAY 41
TERRE HAUTE IN
47802-4749
US

IV. Provider business mailing address

6401 S. US HIGHWAY 41
TERRE HAUTE IN
47802-4749
US

V. Phone/Fax

Practice location:
  • Phone: 812-299-1156
  • Fax: 812-298-3109
Mailing address:
  • Phone: 812-299-1156
  • Fax: 812-298-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: