Provider Demographics
NPI:1609015114
Name:KELLEY, JILL MARIE
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:MARIE
Last Name:KELLEY
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 1:171 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3714
Mailing Address - Country:US
Mailing Address - Phone:207-233-1692
Mailing Address - Fax:
Practice Address - Street 1:81 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6744
Practice Address - Country:US
Practice Address - Phone:207-846-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-08
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEES39677174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist