Healthcare Provider Details

I. General information

NPI: 1184129538
Provider Name (Legal Business Name): JENNA MCCLEAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W WASHINGTON ST RM W041
INDIANAPOLIS IN
46204-2763
US

IV. Provider business mailing address

714 N SENATE AVE STE 200
INDIANAPOLIS IN
46202-3297
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-2035
  • Fax:
Mailing address:
  • Phone: 317-963-1616
  • Fax: 317-963-1621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002432A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: