Provider Demographics
NPI:1437513090
Name:KELLY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KELLY
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 1:1350 LOCUST ST
Mailing Address - Street 2:STE 308
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15219-4738
Mailing Address - Country:US
Mailing Address - Phone:412-942-5629
Mailing Address - Fax:412-942-5638
Practice Address - Street 1:1350 LOCUST ST
Practice Address - Street 2:STE 308
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-4738
Practice Address - Country:US
Practice Address - Phone:412-232-5549
Practice Address - Fax:412-232-8215
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPO15861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA519233VT9Medicare PIN