Provider Demographics
NPI:1679890925
Name:CAMILLERI, JESSICA L (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:CAMILLERI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 3146
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-2353
Practice Address - Fax:317-944-2390
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020048892081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201159590Medicaid
IN145590139Medicare PIN