Provider Demographics
NPI:1043526403
Name:KELLEY, JESSICA LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-0338
Mailing Address - Country:US
Mailing Address - Phone:507-831-8405
Mailing Address - Fax:507-831-4668
Practice Address - Street 1:820 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1761
Practice Address - Country:US
Practice Address - Phone:507-831-8405
Practice Address - Fax:507-831-5668
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR198081-5363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily