MEDICARE: RHONDA S JACKISCH L.M.H.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	39000186A	IN

General Provider Information

NPI Number	:	1881795391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RHONDA S JACKISCH L.M.H.C.

Provider Business Mailing Address
First Line	:	813 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6711
Country	:	US
Telephone Number	:	260-489-8391
Fax Number	:	260-489-6952

Provider Business Practice Location Address
First Line	:	813 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6711
Country	:	US
Telephone Number	:	260-489-8391
Fax Number	:	260-489-6952

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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