Provider Demographics
NPI:1518252410
Name:KILLEEN, JESECA MARTEL (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JESECA
Middle Name:MARTEL
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E 86TH ST
Mailing Address - Street 2:T-1848 STE. 35
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1997
Mailing Address - Country:US
Mailing Address - Phone:617-461-2604
Mailing Address - Fax:
Practice Address - Street 1:1300 E 86TH ST
Practice Address - Street 2:T-1848 STE. 35
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1997
Practice Address - Country:US
Practice Address - Phone:317-810-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023479A183500000X
MAPH25383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist