Provider Demographics
NPI:1073287470
Name:DAUBENSPECK, JESSICA ELLEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:DAUBENSPECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12244 E 116TH ST
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9717
Mailing Address - Country:US
Mailing Address - Phone:317-849-5437
Mailing Address - Fax:317-842-5911
Practice Address - Street 1:12244 E 116TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9717
Practice Address - Country:US
Practice Address - Phone:317-849-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-19-103431106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician