Provider Demographics
NPI:1225121767
Name:ABBOTT, JEANNINE K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:K
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11167
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46856-1167
Mailing Address - Country:US
Mailing Address - Phone:574-546-1900
Mailing Address - Fax:574-546-1999
Practice Address - Street 1:4400 EASTON CMNS STE 125
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6223
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5891103T00000X
OHP.5891103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083266Medicaid
OH0083266Medicaid