Provider Demographics
NPI:1134834765
Name:KELLY, JORDANN HAYLEY
Entity type:Individual
Prefix:
First Name:JORDANN
Middle Name:HAYLEY
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 1:19809 BEVERLY MANOR LN
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5495
Mailing Address - Country:US
Mailing Address - Phone:712-326-1148
Mailing Address - Fax:
Practice Address - Street 1:2231 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3907
Practice Address - Country:US
Practice Address - Phone:402-291-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP52989164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse