Provider Demographics
NPI:1528105202
Name:JARRELL, STEPHEN (LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JARRELL
Suffix:
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1402
Mailing Address - Country:US
Mailing Address - Phone:260-744-4326
Mailing Address - Fax:260-744-0188
Practice Address - Street 1:2712 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1402
Practice Address - Country:US
Practice Address - Phone:260-744-4326
Practice Address - Fax:260-744-0188
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001650A1041C0700X
IN87000362A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200090360AMedicaid
IN146530BMedicare ID - Type Unspecified