Provider Demographics
NPI:1578362331
Name:JENKINS, KELLIE DAWN (PTA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:DAWN
Last Name:JENKINS
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3078 E NEW DISCOVERY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-7011
Mailing Address - Country:US
Mailing Address - Phone:812-564-1128
Mailing Address - Fax:
Practice Address - Street 1:3078 E NEW DISCOVERY RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-7011
Practice Address - Country:US
Practice Address - Phone:812-564-1128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003161A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant