Provider Demographics
NPI:1801866223
Name:SAMELSON, JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:SAMELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E COOLSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-6312
Mailing Address - Country:US
Mailing Address - Phone:219-873-2964
Mailing Address - Fax:219-873-2933
Practice Address - Street 1:104 WOODLAND CT STE B
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7391
Practice Address - Country:US
Practice Address - Phone:219-628-6463
Practice Address - Fax:219-628-6463
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010303A103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100162900Medicaid
P00616032OtherRR MEDICARE
IN000000347073OtherANTHEM
IN000000347073OtherANTHEM
IN100162900Medicaid