Provider Demographics
NPI:1497171409
Name:KELLY, JENNIFER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:9905 AZTEC RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4821
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:(119)
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL161481835P1300X
SC128871835P1300X
CA688031835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric