Active NPI
Jack Ennis, PSYD, HSPP
- Clinical Psychologist
- Indianapolis, IN
National Provider Identifier
1194773028
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 20040742
- Practice address
- 2160 N Illinois St
Indianapolis, IN 46202-1334 - Phone
- (317) 937-3700
- Fax
- (317) 937-3710
- NPI assigned
- May 4, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 20040742 | IN | Primary |
Addresses
Primary practice location
2160 N Illinois St
Indianapolis, IN 46202-1334
Mailing address
PO Box 4323
Terre Haute, IN 47804-0323
Phone (812) 231-8323
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200254160 | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146700800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1300147200000",
"number": "1194773028",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 4323",
"city": "TERRE HAUTE",
"state": "IN",
"postal_code": "478040323",
"telephone_number": "812-231-8323",
"fax_number": "812-231-8400"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2160 N ILLINOIS ST",
"city": "INDIANAPOLIS",
"state": "IN",
"postal_code": "462021334",
"telephone_number": "317-937-3700",
"fax_number": "317-937-3710"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ENNIS",
"first_name": "JACK",
"credential": "PSYD, HSPP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-04",
"last_updated": "2011-03-15",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IN",
"license": "20040742",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200254160",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Indianapolis, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.