Provider Demographics
NPI:1003828880
Name:SPENCER, JENNIFER MICHAEL (PHD HSPP)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHAEL
Last Name:SPENCER
Suffix:
Gender:F
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:MICHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD HSPP
Mailing Address - Street 1:4956 N MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1384
Mailing Address - Country:US
Mailing Address - Phone:812-333-8474
Mailing Address - Fax:
Practice Address - Street 1:631 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3871
Practice Address - Country:US
Practice Address - Phone:812-333-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041405A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200298330Medicaid
INP13825Medicare UPIN