Provider Demographics
NPI:1114357506
Name:SULLIVAN, JILLIAN E (PHD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 S STATE ROAD 135
Practice Address - Street 2:SUITE 230
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9607
Practice Address - Country:US
Practice Address - Phone:317-535-0728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042704A103TC0700X, 103TC1900X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000850729OtherANTHEM BCBS
INP01569147OtherRR MEDICARE
INP01569147OtherRAILROAD PTAN
INP01569147OtherRR MEDICARE
INP01569147OtherRAILROAD PTAN