Provider Demographics
NPI:1538792668
Name:HAVILAND, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E BAILI CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-8686
Mailing Address - Country:US
Mailing Address - Phone:812-614-3248
Mailing Address - Fax:
Practice Address - Street 1:1800 E. STATE ROAD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1846
Practice Address - Country:US
Practice Address - Phone:931-253-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009804A363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health