Provider Demographics
NPI:1225717622
Name:GETTELMAN, JACKSON (LCSW)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:GETTELMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 COTTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-2712
Mailing Address - Country:US
Mailing Address - Phone:812-363-4537
Mailing Address - Fax:
Practice Address - Street 1:2040 N SHADELAND AVE STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1712
Practice Address - Country:US
Practice Address - Phone:317-355-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010514A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical