Provider Demographics
NPI:1326699430
Name:KELLEY, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
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 1:19750 KY 59
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179
Mailing Address - Country:US
Mailing Address - Phone:304-429-6741
Mailing Address - Fax:
Practice Address - Street 1:19750 KY 59
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179
Practice Address - Country:US
Practice Address - Phone:304-429-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider