Provider Demographics
NPI:1770705899
Name:SMITH, JENNIFER KELLER (RD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KELLER
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:SUSAN
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:7164 BRACKEN LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-7838
Mailing Address - Country:US
Mailing Address - Phone:317-851-3841
Mailing Address - Fax:317-865-5083
Practice Address - Street 1:1600 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1541
Practice Address - Country:US
Practice Address - Phone:317-851-3841
Practice Address - Fax:317-865-5083
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001254A133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric