Provider Demographics
NPI:1730311994
Name:CARLSON, JERRI
Entity Type:Individual
Prefix:MS
First Name:JERRI
Middle Name:
Last Name:CARLSON
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 1:3734 ASHLEY OAKS DR
Mailing Address - Street 2:APARTMENT A
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6012
Mailing Address - Country:US
Mailing Address - Phone:765-418-8310
Mailing Address - Fax:
Practice Address - Street 1:3734 ASHLEY OAKS DR
Practice Address - Street 2:APARTMENT A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6012
Practice Address - Country:US
Practice Address - Phone:765-418-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005802A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical