Basic Information
Provider Information | |||||||||
NPI: | 1184970196 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKELL-JEFFERS | ||||||||
FirstName: | GISSELLE | ||||||||
MiddleName: | OLIVIA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SPENCE | ||||||||
OtherFirstName: | GISSELLE | ||||||||
OtherMiddleName: | OLIVIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3645 N BRIARWOOD LN STE A | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473045337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895520 | ||||||||
FaxNumber: | 7652895840 | ||||||||
Practice Location | |||||||||
Address1: | 3645 N BRIARWOOD LN STE A | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473045337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652895520 | ||||||||
FaxNumber: | 7652895840 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2012 | ||||||||
LastUpdateDate: | 10/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC1900X | 20042827A | IN | Y |   | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
ID | Type | State | Issuer | Description | 300051343 | 05 | IN |   | MEDICAID |