Provider Demographics
NPI:1477948230
Name:JIA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JIA
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 1:500 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:717-531-1368
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-1368
Practice Address - Fax:717-531-2077
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.026258207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine