Healthcare Provider Details

I. General information

NPI: 1679796775
Provider Name (Legal Business Name): JACKLYN D KIEFER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 11/27/2023
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 E COUNTY LINE RD STE 101
GREENWOOD IN
46143
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-9050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003257A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02003257A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: