Provider Demographics
NPI:1417931817
Name:KELLY, JENNIFER MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NW WALL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3200
Mailing Address - Country:US
Mailing Address - Phone:541-389-4321
Mailing Address - Fax:541-389-4420
Practice Address - Street 1:55 NW WALL ST STE 100
Practice Address - Street 2:0
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-3200
Practice Address - Country:US
Practice Address - Phone:541-389-4321
Practice Address - Fax:541-389-4420
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4483225100000X
AK1723225100000X
NE2421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299148Medicaid
AK160806Medicare PIN
OR299148Medicaid