Basic Information
Provider Information | |||||||||
NPI: | 1831686138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KINN | ||||||||
FirstName: | JENNA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MOT, OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462686135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8553240885 | ||||||||
FaxNumber: | 7654549759 | ||||||||
Practice Location | |||||||||
Address1: | 4422 E STATE BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468156917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604719263 | ||||||||
FaxNumber: | 7654549759 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2018 | ||||||||
LastUpdateDate: | 07/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | 31006592A | IN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.