Provider Demographics
NPI:1821390436
Name:KELLEY, JEFFREY GLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:GLEN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:1840 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-3199
Practice Address - Country:US
Practice Address - Phone:615-217-1560
Practice Address - Fax:615-890-7838
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018735Medicaid
TN6026014OtherBCBS TN
TN103I977895Medicare PIN