Provider Demographics
NPI:1194773028
Name:ENNIS, JACK (PSYD, HSPP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ENNIS
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4323
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-0323
Mailing Address - Country:US
Mailing Address - Phone:812-231-8323
Mailing Address - Fax:812-231-8400
Practice Address - Street 1:2160 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1334
Practice Address - Country:US
Practice Address - Phone:317-937-3700
Practice Address - Fax:317-937-3710
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040742103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200254160Medicaid
IN200254160Medicaid