Provider Demographics
NPI:1790727147
Name:KELLY, JEANNE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARIE
Last Name:KELLY
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 1:455 WOODVIEW RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-9303
Mailing Address - Country:US
Mailing Address - Phone:610-345-1900
Mailing Address - Fax:
Practice Address - Street 1:455 WOODVIEW RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9303
Practice Address - Country:US
Practice Address - Phone:610-345-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038235E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000357901Medicaid