Provider Demographics
NPI:1558500165
Name:KIELLACH, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIELLACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 FRUITVILLE RD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2268
Mailing Address - Country:US
Mailing Address - Phone:941-377-9361
Mailing Address - Fax:941-371-7657
Practice Address - Street 1:5045 FRUITVILLE RD
Practice Address - Street 2:SUITE 145
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2268
Practice Address - Country:US
Practice Address - Phone:941-377-9361
Practice Address - Fax:941-371-7657
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9946225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist