Provider Demographics
NPI:1891468443
Name:KELLEY, JADE (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:JADE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 NORTHERN CEDAR AVE NW APT 111
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2885
Mailing Address - Country:US
Mailing Address - Phone:218-686-6226
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1511
Practice Address - Country:US
Practice Address - Phone:218-732-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist