Provider Demographics
NPI:1538518642
Name:KILEY, JENNIFER M (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:M
Last Name:KILEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 INFANTRY POST RD
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-1306
Mailing Address - Country:US
Mailing Address - Phone:206-280-1142
Mailing Address - Fax:
Practice Address - Street 1:3145 GARDEN AVE
Practice Address - Street 2:STE 1278
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7718
Practice Address - Country:US
Practice Address - Phone:210-808-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16598124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist