Basic Information
| Provider Information | |||||||||
| NPI: | 1013279835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | JEANIE | ||||||||
| MiddleName: | HAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAN | ||||||||
| OtherFirstName: | JEANIE | ||||||||
| OtherMiddleName: | YOUNGMEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 ESKENAZI AVENUE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG., 5TH FLOOR | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176704507 | ||||||||
| FaxNumber: | 3178800498 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 ESKENAZI AVENUE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178805542 | ||||||||
| FaxNumber: | 3175542721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.