Provider Demographics
NPI:1437696804
Name:KELLY, JILL (LAC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 DAYTON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-2789
Mailing Address - Country:US
Mailing Address - Phone:423-843-3700
Mailing Address - Fax:
Practice Address - Street 1:6212 DAYTON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-2789
Practice Address - Country:US
Practice Address - Phone:423-843-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist