Provider Demographics
NPI:1275015901
Name:KEITH, JENNIFER (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEITH
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KEMPFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-890-2000
Mailing Address - Fax:317-859-7220
Practice Address - Street 1:2907 S MCINTIRE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4225
Practice Address - Country:US
Practice Address - Phone:317-890-2000
Practice Address - Fax:317-859-7220
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002549A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002549AOtherSTATE LICENSE NUMBER