=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881853182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE UNITED METHODIST YOUTH HOME INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 06/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2521 N BURKHARDT RD
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-479-7535
-----------------------------------------------------
Fax | 812-475-7203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2521 N BURKHARDT RD
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-479-7535
-----------------------------------------------------
Fax | 812-475-7203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. BARBARA C. JESSEN
-----------------------------------------------------
Credential | PSY D
-----------------------------------------------------
Telephone | 812-479-7535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 210257A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------