Provider Demographics
NPI:1609049774
Name:KELLY, JONATHON LUTHER (IDC)
Entity Type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:LUTHER
Last Name:KELLY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 BOONE RD
Mailing Address - Street 2:NAVAL HOSPITAL BREMERTON
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:360-475-4841
Mailing Address - Fax:360-475-4935
Practice Address - Street 1:1 BOONE RD
Practice Address - Street 2:NAVAL HOSPITAL BREMERTON
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1894
Practice Address - Country:US
Practice Address - Phone:360-475-4841
Practice Address - Fax:360-475-4935
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman