Provider Demographics
NPI:1598759722
Name:FISHER, JEFFREY L (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:FISHER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 LAKE AVE
Mailing Address - Street 2:VA NORTHERN INDIANA
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:56805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:260-460-1482
Practice Address - Street 1:2121 LAKE AVE.
Practice Address - Street 2:VA NORTHERN INDIANA HEALTH CARE SYSTEM
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:56805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-460-1482
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041565S103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200319750Medicaid
P39597Medicare UPIN
IN200319750Medicaid