Provider Demographics
NPI:1205213386
Name:PICKETT, JUDITH JANE
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:JANE
Last Name:PICKETT
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 1:7517 BEECHWOOD CENTRE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7879
Mailing Address - Country:US
Mailing Address - Phone:317-272-8138
Mailing Address - Fax:317-272-8165
Practice Address - Street 1:7517 BEECHWOOD CENTRE RD STE 300
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7879
Practice Address - Country:US
Practice Address - Phone:317-272-8138
Practice Address - Fax:317-272-8165
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000854A101YM0800X
IN33002334A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health