Provider Demographics
NPI:1205893021
Name:KELTY, JENNY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:LEE
Last Name:KELTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LEE
Other - Last Name:YUNSU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2730 B PROSPERITY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2238
Mailing Address - Country:US
Mailing Address - Phone:703-289-1400
Mailing Address - Fax:703-289-1414
Practice Address - Street 1:2730 A PROSPERITY AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2238
Practice Address - Country:US
Practice Address - Phone:703-289-1410
Practice Address - Fax:703-289-1420
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012368402080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010103797Medicaid
VA010103789Medicaid
VA0101037762Medicaid
VA010087309Medicaid