Provider Demographics
NPI:1558015776
Name:KELLY, JENNIFER RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 STEMBRIDGE CT APT C
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-3050
Mailing Address - Country:US
Mailing Address - Phone:804-840-8621
Mailing Address - Fax:
Practice Address - Street 1:7246 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-1524
Practice Address - Country:US
Practice Address - Phone:804-320-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606068225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant