Provider Demographics
NPI:1659042224
Name:KIETZMAN, JENNA (OTD, OTR)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:KIETZMAN
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 MISSOURI AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3084
Mailing Address - Country:US
Mailing Address - Phone:812-288-4688
Mailing Address - Fax:812-610-8333
Practice Address - Street 1:590 MISSOURI AVE STE 204
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3084
Practice Address - Country:US
Practice Address - Phone:812-288-4688
Practice Address - Fax:812-610-8333
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY272624225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist