Provider Demographics
NPI:1629143284
Name:KRISTELLER, JEAN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:L
Last Name:KRISTELLER
Suffix:
Gender:F
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:PSYCHOLOGY DEPARTMENT
Mailing Address - Street 2:INDIANA STATE UNIVERSITY
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47809-0001
Mailing Address - Country:US
Mailing Address - Phone:812-237-2467
Mailing Address - Fax:812-237-4378
Practice Address - Street 1:4435 LANCASHIRE CT
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-2092
Practice Address - Country:US
Practice Address - Phone:812-877-3760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040676A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200280980Medicaid