Provider Demographics
NPI:1235367616
Name:KLUETZ, JESSICA J (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:J
Last Name:KLUETZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JEAN
Other - Last Name:HARLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
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 1:355 W 16TH ST
Practice Address - Street 2:SUITE 4300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7077
Practice Address - Fax:317-963-7068
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.056282207R00000X, 208100000X
IN02004220A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201162640Medicaid
IN201162640Medicaid