Provider Demographics
NPI:1063460558
Name:KELLY, JENNIFER JO (RN, CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CNP
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 5021
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:513-636-9079
Mailing Address - Fax:513-636-7576
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 5006 DIABETES CLINIC
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-636-9079
Practice Address - Fax:513-636-7576
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.08014-NP363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2656951Medicaid
OH2656951Medicaid