Provider Demographics
NPI:1104515642
Name:SPURLOCK, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SPURLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 E STATE ROAD 44 TRLR 11
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1700
Mailing Address - Country:US
Mailing Address - Phone:317-512-8841
Mailing Address - Fax:
Practice Address - Street 1:1203 E STATE ROAD 44 TRLR 11
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1700
Practice Address - Country:US
Practice Address - Phone:317-512-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician