Healthcare Provider Details

I. General information

NPI: 1871260570
Provider Name (Legal Business Name): DJKKM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 WOLF RIDGE CT
NEW ALBANY IN
47150-9590
US

IV. Provider business mailing address

3040 WOLF RIDGE CT
NEW ALBANY IN
47150-9590
US

V. Phone/Fax

Practice location:
  • Phone: 812-989-6349
  • Fax:
Mailing address:
  • Phone: 812-989-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANN DOUGLAS
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTRL
Phone: 812-989-6349