Provider Demographics
NPI:1043588551
Name:KALK, KELLY JAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JAYNE
Last Name:KALK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SE DOWSETT LN
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7816
Mailing Address - Country:US
Mailing Address - Phone:503-936-5098
Mailing Address - Fax:
Practice Address - Street 1:700 SE DOWSETT LN
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-7816
Practice Address - Country:US
Practice Address - Phone:503-936-5098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR5012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health