Individual
JACK ENNIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSYD, HSPP
Contact information
Practice address
2160 N ILLINOIS ST, INDIANAPOLIS, IN 46202-1334
(317) 937-3700
(317) 937-3710
Mailing address
PO BOX 4323, TERRE HAUTE, IN 47804-0323
(812) 231-8323
(812) 231-8400
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
20040742
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200254160
—
IN
Enumeration date
05/04/2006
Last updated
03/15/2011
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