Provider Demographics
NPI:1932331345
Name:JENNIFER SPENCER PHD HSPP PC
Entity Type:Organization
Organization Name:JENNIFER SPENCER PHD HSPP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD HSPP
Authorized Official - Phone:812-333-8474
Mailing Address - Street 1:482 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5000
Mailing Address - Country:US
Mailing Address - Phone:812-333-8474
Mailing Address - Fax:812-961-3804
Practice Address - Street 1:482 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5000
Practice Address - Country:US
Practice Address - Phone:812-333-8474
Practice Address - Fax:812-961-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041405251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200298330Medicaid
INP13825Medicare UPIN