Provider Demographics
NPI:1689800401
Name:JONES, KELLY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3533
Mailing Address - Country:US
Mailing Address - Phone:414-266-2979
Mailing Address - Fax:
Practice Address - Street 1:1000 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3533
Practice Address - Country:US
Practice Address - Phone:414-266-2979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74976207SG0201X
MS23778207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05788256Medicaid
WI1689800401Medicaid