Provider Demographics
NPI:1912970625
Name:GUMERSON, JERELYN J (NP)
Entity Type:Individual
Prefix:MRS
First Name:JERELYN
Middle Name:J
Last Name:GUMERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0044
Mailing Address - Fax:888-700-0187
Practice Address - Street 1:3834 S EMERSON AVE
Practice Address - Street 2:BUILDING C, SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-782-1577
Practice Address - Fax:317-780-5539
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000562A2084P0800X, 2084P0805X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01424889OtherMEDICARE RAILROAD PIN
IN200215810Medicaid
IN149980FMedicare ID - Type Unspecified
INP01424889OtherMEDICARE RAILROAD PIN
INS82902Medicare UPIN