Provider Demographics
NPI:1750645446
Name:KELSO, JENNIFER SUZANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:KELSO
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 1:11020 19TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5155
Mailing Address - Country:US
Mailing Address - Phone:425-337-7197
Mailing Address - Fax:425-337-9287
Practice Address - Street 1:11020 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5155
Practice Address - Country:US
Practice Address - Phone:425-337-7197
Practice Address - Fax:425-337-9287
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60054959183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician