Provider Demographics
NPI:1013956549
Name:KELSO, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KELSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1050
Mailing Address - Fax:704-316-1051
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 175
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-316-1050
Practice Address - Fax:704-316-1051
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800297207P00000X
MI4301074437207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI930084992OtherRR MEDICARE
MI104144930Medicaid
MI930084992OtherRR MEDICARE
MIM88560014Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL