Basic Information
| Provider Information | |||||||||
| NPI: | 1639158413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JANEL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738000 | ||||||||
| FaxNumber: | 2603738034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 BEACON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738000 | ||||||||
| FaxNumber: | 2603738034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 07/28/2008 | ||||||||
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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 | 103T00000X | 20040322A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000000203700 | 01 | IN | ANTHEM | OTHER | P00293052 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000543925 | 01 | IN | ANTHEM | OTHER | 100384920 | 05 | IN | MEDICAID | P00478525 | 01 | IN | RAILROAD MEDICARE | OTHER | 1771 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER |