Provider Demographics
NPI:1417057779
Name:JONES, KELLY N (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24397
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1397
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1953
Practice Address - Country:US
Practice Address - Phone:618-624-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116148207Q00000X
IL036116148207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116148Medicaid
ILP00369032OtherRAILROAD MEDICARE
IL08232205OtherBLUE CROSS BLUE SHIELD
IL036116148Medicaid
ILP00369032OtherRAILROAD MEDICARE