Provider Demographics
NPI:1477191088
Name:KUTZ, JESSICA LYNN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:KUTZ
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 ARBOR LAKE LN APT 728
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4299
Mailing Address - Country:US
Mailing Address - Phone:317-902-2099
Mailing Address - Fax:
Practice Address - Street 1:19000 E 191ST STREET
Practice Address - Street 2:SUITE K
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002359A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
200018552OtherBOARD OF CERTIFICATION NUMBER
IN36002359AOtherIN ATHLETIC TRAINING LICENSE