Provider Demographics
NPI:1295004372
Name:MERTZ, JESSICA ELAINE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ELAINE
Last Name:MERTZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 S PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8836
Mailing Address - Country:US
Mailing Address - Phone:317-887-7165
Mailing Address - Fax:317-887-7340
Practice Address - Street 1:98 S PARK BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8836
Practice Address - Country:US
Practice Address - Phone:317-887-7165
Practice Address - Fax:317-887-7340
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001707A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer