Provider Demographics
NPI:1376940627
Name:KELLAMS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KELLAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KLEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:534 E GRAHAM PL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4530
Mailing Address - Country:US
Mailing Address - Phone:317-379-1209
Mailing Address - Fax:
Practice Address - Street 1:534 E GRAHAM PL
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4530
Practice Address - Country:US
Practice Address - Phone:317-379-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005722235Z00000X
CASP 22380235Z00000X
WALL 60507504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP 22380OtherSPEECH LANGUAGE PATHOLOGY & AUDIOLOGY & HEARING AID DISPENSERS BOARD
WALL 60507504OtherDEPARTMENT OF HEALTH, WASHINGTON STATE
IN22005722OtherINDIANA PUBLIC LICENSING AGENCY, SPEECH-LANGUAGE PATHOLOGY