Healthcare Provider Details

I. General information

NPI: 1205968245
Provider Name (Legal Business Name): JENNIFER MARLENE KALETH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 N CAPITOL AVE STE 600
INDIANAPOLIS IN
46202-1288
US

IV. Provider business mailing address

1815 N CAPITOL AVE STE 600
INDIANAPOLIS IN
46202-1288
US

V. Phone/Fax

Practice location:
  • Phone: 317-924-8636
  • Fax: 317-921-0230
Mailing address:
  • Phone: 317-924-8636
  • Fax: 317-921-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number05005648A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number05005648A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: