Provider Demographics
NPI:1790322758
Name:KELLY, JENNIFER LEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:KELLY
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 1:4519 STANBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4021
Mailing Address - Country:US
Mailing Address - Phone:804-882-6351
Mailing Address - Fax:
Practice Address - Street 1:4519 STANBROOK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-4021
Practice Address - Country:US
Practice Address - Phone:804-882-6351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide