Provider Demographics
NPI:1144767344
Name:JENNE, KELLY D (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:JENNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:KASTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:812-676-4542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28209377A363LF0000X
IN71007550A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP02474299OtherRAILROAD PTAN
IN300008240Medicaid
IN068010568OtherMEDICARE PTAN
IN090540375OtherMEDICARE PTAN