Provider Demographics
NPI:1447668009
Name:JACK, KENDRA KELLER (OTR/L)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:KELLER
Last Name:JACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 CLERMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1990
Mailing Address - Country:US
Mailing Address - Phone:513-735-8300
Mailing Address - Fax:
Practice Address - Street 1:2400 CLERMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1990
Practice Address - Country:US
Practice Address - Phone:513-735-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009954283XC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283XC2000XHospitalsRehabilitation HospitalChildren