Provider Demographics
NPI:1679307151
Name:MITTAL, JENNIFER (MED)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MITTAL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-3416
Mailing Address - Country:US
Mailing Address - Phone:765-225-1181
Mailing Address - Fax:
Practice Address - Street 1:305 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3416
Practice Address - Country:US
Practice Address - Phone:765-362-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1017541103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool