Provider Demographics
NPI:1184970196
Name:MCKELL-JEFFERS, GISSELLE OLIVIA (PHD)
Entity type:Individual
Prefix:DR
First Name:GISSELLE
Middle Name:OLIVIA
Last Name:MCKELL-JEFFERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GISSELLE
Other - Middle Name:OLIVIA
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3645 N BRIARWOOD LN STE A
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5337
Mailing Address - Country:US
Mailing Address - Phone:765-289-5520
Mailing Address - Fax:765-289-5840
Practice Address - Street 1:3645 N BRIARWOOD LN STE A
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5337
Practice Address - Country:US
Practice Address - Phone:765-289-5520
Practice Address - Fax:765-289-5840
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN20042827A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300051343Medicaid