Individual
JILL CHERIE FODSTAD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD, HSPP
Contact information
Practice address
705 RILEY HOSPITAL DR, INDIANAPOLIS, IN 46202-5109
(317) 944-2066
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
05202
MD
103T00000X
Psychologist
Primary
20042696A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201183590
—
IN
Enumeration date
09/10/2012
Last updated
01/21/2021
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