Basic Information
| Provider Information | |||||||||
| NPI: | 1679796775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIEFER | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 533 E COUNTY LINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179579050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02003257A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 02003257A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00885864 | 01 | OH | RR MEDICARE | OTHER | 2957966 | 05 | OH | MEDICAID |