Provider Demographics
NPI:1407858129
Name:DAVIS, HENRY JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:JEFFREY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 WILLOWBROOK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1564
Mailing Address - Country:US
Mailing Address - Phone:317-574-1254
Mailing Address - Fax:317-674-0060
Practice Address - Street 1:9615 E 148TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4360
Practice Address - Country:US
Practice Address - Phone:317-587-0533
Practice Address - Fax:317-674-0060
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010296A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100128540Medicaid
IN100128540Medicaid