Provider Demographics
NPI:1225092901
Name:KALETA, JENNIFER LYNN (DPM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KALETA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 FEEHANVILLE DR STE 450
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-6023
Mailing Address - Country:US
Mailing Address - Phone:847-390-7666
Mailing Address - Fax:847-390-9345
Practice Address - Street 1:24024 BRANCASTER DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8044
Practice Address - Country:US
Practice Address - Phone:847-390-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004910213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU82743Medicare UPIN
IL1633808OtherBC BS ILLINOIS
IL207100001Medicare PIN
IL5048120002OtherDMERC
IL5048120002Medicare NSC
IL016004910Medicaid