Provider Demographics
NPI:1275808917
Name:MYSOGLAND, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MYSOGLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 SUMMERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-9247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6330 E 75TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2777
Practice Address - Country:US
Practice Address - Phone:317-577-5948
Practice Address - Fax:317-577-5954
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005721A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical