1477191088 NPI number — JESSICA LYNN KUTZ LAT, ATC

Table of content: JESSICA LYNN KUTZ LAT, ATC (NPI 1477191088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477191088 NPI number — JESSICA LYNN KUTZ LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUTZ
Provider First Name:
JESSICA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477191088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2553 ARBOR LAKE LN APT 728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-4299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-902-2099
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19000 E 191ST STREET
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
WESTFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-817-1200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  36002359A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200018552 . This is a "BOARD OF CERTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36002359A . This is a "IN ATHLETIC TRAINING LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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