Provider Demographics
NPI:1194708966
Name:JASPER, JAMES ANTHONY (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ANTHONY
Last Name:JASPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:FRANK
Other - Middle Name:JAMES
Other - Last Name:JASPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1530 UNION ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46225-1672
Mailing Address - Country:US
Mailing Address - Phone:317-638-5552
Mailing Address - Fax:317-338-6844
Practice Address - Street 1:8402 HARCOURT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2074
Practice Address - Country:US
Practice Address - Phone:317-338-6085
Practice Address - Fax:317-338-6844
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040758A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR33072Medicare UPIN
IN207380Medicare ID - Type Unspecified