Provider Demographics
NPI:1821301961
Name:KELLY, KENNETH JASON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JASON
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:300B TEMPLE LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2973
Practice Address - Country:US
Practice Address - Phone:804-524-9036
Practice Address - Fax:804-524-9039
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192946OtherBCBS (PHYSICAL THERAPY)
VA1821301961Medicaid
VA9631527OtherAETNA
VA192946OtherBCBS (PHYSICAL THERAPY)
VAVAA102540Medicare PIN