Provider Demographics
NPI:1417208000
Name:DR JAN KELLEY PA
Entity Type:Organization
Organization Name:DR JAN KELLEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-625-2667
Mailing Address - Street 1:3400 TAMIAMI TRL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8102
Mailing Address - Country:US
Mailing Address - Phone:941-625-2667
Mailing Address - Fax:
Practice Address - Street 1:3400 TAMIAMI TRL
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8102
Practice Address - Country:US
Practice Address - Phone:941-625-2667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6944F111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU29428Medicare UPIN