Provider Demographics
NPI:1275243438
Name:KELLEY, JEANNINE YVETTE
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:YVETTE
Last Name:KELLEY
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 1:2176 LISTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-2834
Mailing Address - Country:US
Mailing Address - Phone:614-817-5295
Mailing Address - Fax:
Practice Address - Street 1:2176 LISTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-2834
Practice Address - Country:US
Practice Address - Phone:614-817-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals