Provider Demographics
NPI:1083923130
Name:KELLY, JILLIAN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CITY HALL MALL
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4754
Mailing Address - Country:US
Mailing Address - Phone:781-306-5304
Mailing Address - Fax:781-306-5227
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5304
Practice Address - Fax:781-306-5227
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA275375363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health