Provider Demographics
NPI:1710245949
Name:CLEAVES, KELLY JEAN (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:CLEAVES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12160 SW FAIRCREST ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4620
Mailing Address - Country:US
Mailing Address - Phone:402-650-8834
Mailing Address - Fax:
Practice Address - Street 1:18650 NW CORNELL RD
Practice Address - Street 2:STE 315
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9207
Practice Address - Country:US
Practice Address - Phone:503-352-0468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDO1721662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program