Basic Information
| Provider Information | |||||||||
| NPI: | 1912970625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUMERSON | ||||||||
| FirstName: | JERELYN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3299 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897023299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752220044 | ||||||||
| FaxNumber: | 8887000187 | ||||||||
| Practice Location | |||||||||
| Address1: | 3834 S EMERSON AVE | ||||||||
| Address2: | BUILDING C, SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177821577 | ||||||||
| FaxNumber: | 3177805539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2006 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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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 | 2084P0800X | 71000562A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 71000562A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 363LF0000X | 71000562A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01424889 | 01 | IN | MEDICARE RAILROAD PIN | OTHER | 200215810 | 05 | IN | MEDICAID |