Provider Demographics
NPI:1407890445
Name:JONES, EDLYN N (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:EDLYN
Middle Name:N
Last Name:JONES
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6820 PARKDALE PLACE
Practice Address - Street 2:SUITE 115
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4699
Practice Address - Country:US
Practice Address - Phone:317-329-7300
Practice Address - Fax:317-329-7325
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040806103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200123130Medicaid
INS79855Medicare UPIN
INM400015368Medicare PIN
IN200123130Medicaid