Provider Demographics
NPI:1558776138
Name:JAIN, IVANSHU NAVINPRAKASH (MD)
Entity Type:Individual
Prefix:DR
First Name:IVANSHU
Middle Name:NAVINPRAKASH
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E BRIN ST
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-2938
Mailing Address - Country:US
Mailing Address - Phone:972-563-6452
Mailing Address - Fax:
Practice Address - Street 1:TERRELL STATE HOSPITAL
Practice Address - Street 2:1200 E BRIN ST
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160
Practice Address - Country:US
Practice Address - Phone:972-563-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR72332084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program