Basic Information
| Provider Information | |||||||||
| NPI: | 1568415263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | Z | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SOUTHFIELD DR | ||||||||
| Address2: | SUITE 1370 | ||||||||
| City: | PLAINFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461684498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178375571 | ||||||||
| FaxNumber: | 3178375580 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461221989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177184730 | ||||||||
| FaxNumber: | 3177184733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | 01052541A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | 01052541 | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 200267720 | 05 | IN | MEDICAID |