Provider Demographics
NPI:1790189843
Name:KELLY, JACKIE (APRN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 STATE HIGHWAY 70 N
Mailing Address - Street 2:
Mailing Address - City:ROTAN
Mailing Address - State:TX
Mailing Address - Zip Code:79546-6918
Mailing Address - Country:US
Mailing Address - Phone:325-735-2211
Mailing Address - Fax:325-735-2240
Practice Address - Street 1:774 STATE HIGHWAY 70 N
Practice Address - Street 2:
Practice Address - City:ROTAN
Practice Address - State:TX
Practice Address - Zip Code:79546-6918
Practice Address - Country:US
Practice Address - Phone:325-735-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily