Provider Demographics
NPI:1013083203
Name:KELLY, JENNIFER L (MSPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:PT-ONE
Other - Middle Name:
Other - Last Name:PHYSICAL THERAPY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3455 W PENN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1438
Mailing Address - Country:US
Mailing Address - Phone:610-368-8390
Mailing Address - Fax:
Practice Address - Street 1:3455 W PENN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1438
Practice Address - Country:US
Practice Address - Phone:610-368-8390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2016-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013908L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT013908LOtherPHYSICAL THERAPIST LIC