Provider Demographics
NPI:1205968245
Name:KALETH, JENNIFER MARLENE (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARLENE
Last Name:KALETH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 N CAPITOL AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1288
Mailing Address - Country:US
Mailing Address - Phone:317-924-8636
Mailing Address - Fax:317-921-0230
Practice Address - Street 1:1815 N CAPITOL AVE
Practice Address - Street 2:STE 600
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1288
Practice Address - Country:US
Practice Address - Phone:317-924-8636
Practice Address - Fax:317-921-0230
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005648A2251X0800X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200676540OtherEARLY INTERVENTION
IN200539340Medicaid