Basic Information
| Provider Information | |||||||||
| NPI: | 1194020537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURVIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAIL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3117 RADFORD DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462266227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176505315 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 940 LASLEY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654827421 | ||||||||
| FaxNumber: | 7654827462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2011 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34006957A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.