MEDICARE: JENNIFER KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26022982A	IN

General Provider Information

NPI Number	:	1033495346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER KELLY

Provider Business Mailing Address
First Line	:	937 JUNCTION PL
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4278
Country	:	US
Telephone Number	:	260-450-2172
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 E RAYMOND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-4143
Country	:	US
Telephone Number	:	317-784-7979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	11/01/2011

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