Provider Demographics
NPI:1679395883
Name:GRELLE, JACLYN (EDS)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GRELLE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:GRELLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDS
Mailing Address - Street 1:6861 WALNUT BEND RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5233
Mailing Address - Country:US
Mailing Address - Phone:317-650-2263
Mailing Address - Fax:
Practice Address - Street 1:6740 W MORRIS ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-1719
Practice Address - Country:US
Practice Address - Phone:317-988-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10140084103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool