Provider Demographics
NPI:1528590197
Name:STOUT, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2385
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5885
Mailing Address - Country:US
Mailing Address - Phone:844-896-0235
Mailing Address - Fax:219-898-4258
Practice Address - Street 1:1595 S CALUMET RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2388
Practice Address - Country:US
Practice Address - Phone:844-896-0235
Practice Address - Fax:219-898-4258
Is Sole Proprietor?:No
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid