Provider Demographics
NPI:1891421376
Name:KELLY, JAMIE A
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 CRANBERRY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-3508
Mailing Address - Country:US
Mailing Address - Phone:732-995-9405
Mailing Address - Fax:
Practice Address - Street 1:595 SHREWSBURY AVE STE 103
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4159
Practice Address - Country:US
Practice Address - Phone:732-741-5923
Practice Address - Fax:732-741-2759
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00721800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant