Provider Demographics
NPI:1235246729
Name:KELLY, JARENA JAN (DNP,APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:JARENA
Middle Name:JAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DNP,APRN-BC
Other - Prefix:
Other - First Name:JARENA
Other - Middle Name:J
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:506 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1204
Practice Address - Country:US
Practice Address - Phone:304-766-8558
Practice Address - Fax:304-766-8561
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41613363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WV3810023573Medicaid
WV3810024049OtherGROUP MEDICAID
WVWV1435B441Medicare PIN