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General NPI Number Information
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NPI Number | 1578372850
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Entity Type | Individual
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Provider Name | JENNIFER MARIE KELLY
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Gender | Female
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Dates
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Enumeration Date | 01/02/2025
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 53940 CARMICHAEL DR
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City | SOUTH BEND
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State | IN
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Zip | 46635-1564
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Country | US
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Telephone | 574-335-6212
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Fax |
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Provider Business Mailing Address
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Address Line | 611 E DOUGLAS RD STE 140
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City | MISHAWAKA
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State | IN
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Zip | 46545-1464
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Country | US
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Telephone | 574-335-6212
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 06005944A
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License Number State | IN
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