Provider Demographics
NPI:1083881007
Name:JENNINGS, KELLY (ND, MSOM)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:ND, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1544
Mailing Address - Country:US
Mailing Address - Phone:503-445-9771
Mailing Address - Fax:
Practice Address - Street 1:4900 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1544
Practice Address - Country:US
Practice Address - Phone:503-444-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1620175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath