Provider Demographics
NPI:1861860058
Name:KELSEY, JENNIFER MICHELLE (APN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:KELSEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVENUE, SUITE 401
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603
Mailing Address - Country:US
Mailing Address - Phone:815-530-4682
Mailing Address - Fax:
Practice Address - Street 1:420 NE GLEN OAK AVENUE, SUITE 401
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:815-530-4682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012384364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist