=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184122426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MARIE-HYSLOP BIGELOW MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2018
-----------------------------------------------------
Last Update Date | 01/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10080 E US HIGHWAY 36 STE A
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46123-8174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-790-9396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10080 E US HIGHWAY 36 STE A
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46123-8174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-790-9396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34004725A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------