Provider Demographics
NPI:1184204646
Name:KELLY, JESSICA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E CAMELBACK RD UNIT 2139
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3696
Mailing Address - Country:US
Mailing Address - Phone:805-458-4267
Mailing Address - Fax:
Practice Address - Street 1:6339 E GREENWAY RD STE 102
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6524
Practice Address - Country:US
Practice Address - Phone:805-458-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation