Provider Demographics
NPI:1669549440
Name:KELLEMS, JENNIFER LYNN (OD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:KELLEMS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12270 SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:LEOPOLD
Mailing Address - State:IN
Mailing Address - Zip Code:47551-8950
Mailing Address - Country:US
Mailing Address - Phone:812-719-8219
Mailing Address - Fax:812-738-7116
Practice Address - Street 1:849 PACER DR NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2145
Practice Address - Country:US
Practice Address - Phone:812-738-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003361B152W00000X
IN18003361A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist