Provider Demographics
NPI:1912046004
Name:DALTON, JIM L (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:L
Last Name:DALTON
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6067 DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-9606
Mailing Address - Country:US
Mailing Address - Phone:317-281-4545
Mailing Address - Fax:317-856-2333
Practice Address - Street 1:6067 DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-9606
Practice Address - Country:US
Practice Address - Phone:317-281-4545
Practice Address - Fax:317-856-2333
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041365A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical