Provider Demographics
NPI:1205419330
Name:KELLY-MOTAMED, JILLIAN AILEEN (MD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:AILEEN
Last Name:KELLY-MOTAMED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:AILEEN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5029
Mailing Address - Country:US
Mailing Address - Phone:877-960-3426
Mailing Address - Fax:
Practice Address - Street 1:250 W 5TH ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5029
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA196332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program