Provider Demographics
NPI:1114558327
Name:JAGER, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:JAGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 N 32ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-8567
Mailing Address - Country:US
Mailing Address - Phone:269-203-7385
Mailing Address - Fax:269-216-7634
Practice Address - Street 1:8801 N 32ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-8567
Practice Address - Country:US
Practice Address - Phone:269-203-7385
Practice Address - Fax:269-216-7634
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist