MEDICARE: JACK KESSEY

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	133V00000X	Registered Dietitian	37003210A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86104699	OTHER	IN	COMMISSION ON DIETETIC COMMISSION

General Provider Information

NPI Number	:	1093531600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK KESSEY

Provider Business Mailing Address
First Line	:	9525 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1310
Country	:	US
Telephone Number	:	317-210-3244
Fax Number	:

Provider Business Practice Location Address
First Line	:	9525 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1310
Country	:	US
Telephone Number	:	317-210-3244
Fax Number	:

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

Provider Enumeration Date	:	11/27/2024
Last Update Date	:	11/27/2024

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Directions to “ JACK KESSEY ” Practice Location

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