Provider Demographics
NPI:1750752853
Name:COUNCELLER, JENNIFER L (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:COUNCELLER
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-825-8446
Mailing Address - Fax:765-827-0013
Practice Address - Street 1:1473 E STATE ROAD 44
Practice Address - Street 2:WHITEWATER VALLEY PRIMARY CARE
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8374
Practice Address - Country:US
Practice Address - Phone:765-825-8446
Practice Address - Fax:765-827-0013
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2021-05-13
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Provider Licenses
StateLicense IDTaxonomies
IN71005873A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201325910Medicaid
OH0150521Medicaid
000000965537OtherANTHEM (REID PHYSICIAN ASSOCIATES, INC.)
IN201325910Medicaid