Provider Demographics
NPI:1750921540
Name:PHELPS, JENNIFER DIANE (OT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7725 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2504
Mailing Address - Country:US
Mailing Address - Phone:317-253-1481
Mailing Address - Fax:
Practice Address - Street 1:7725 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-2504
Practice Address - Country:US
Practice Address - Phone:317-253-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003876A225X00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist