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General NPI Number Information
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NPI Number | 1043928187
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Entity Type | Organization
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Legal Business Name | IDENTITY OUTREACH PROGRAM CORP.
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 03/12/2023
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Provider Practice Location Address
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Address Line | 7098 N SHADELAND AVE STE F
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-4275
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Country | US
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Telephone | 317-771-3006
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Fax |
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Provider Business Mailing Address
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Address Line | 7098 N SHADELAND AVE STE F
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-4275
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Country | US
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Telephone | 317-771-3006
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Fax |
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Authorized Official
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Title or Position | CEO/FOUNDER
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Name | JASMINE TUCKER
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Credential |
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Telephone | 317-771-3006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State |
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