Provider Demographics
NPI:1376823542
Name:LOVE, JACQUELYN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:LOVE
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 1:175 COUNTRY CLUB ESTATES DR SE
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-1799
Mailing Address - Country:US
Mailing Address - Phone:260-450-1417
Mailing Address - Fax:
Practice Address - Street 1:3526 EPHRAIM MCDOWELL DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3224
Practice Address - Country:US
Practice Address - Phone:260-450-1417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173460103TC0700X
IN20042997A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical