Provider Demographics
NPI:1851429229
Name:CHARLES, JERI KELLETT (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JERI
Middle Name:KELLETT
Last Name:CHARLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1326
Mailing Address - Country:US
Mailing Address - Phone:903-927-3782
Mailing Address - Fax:903-927-1764
Practice Address - Street 1:620 S GROVE ST STE 105
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5295
Practice Address - Country:US
Practice Address - Phone:039-359-4419
Practice Address - Fax:903-938-1246
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68260-3151363LF0000X
TXAP113202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP113202OtherTX LICENSE
TX166949101Medicaid