Provider Demographics
NPI:1508640491
Name:JONES, KELLI D'NELL
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:D'NELL
Last Name:JONES
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 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-523-4573
Mailing Address - Fax:
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0510
Practice Address - Country:US
Practice Address - Phone:209-523-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-EHKJO175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist