Provider Demographics
NPI:1255012654
Name:JETTE-KELLY, SHELLEY (PMHNP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:JETTE-KELLY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 BROADWAY STE 303
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4454
Mailing Address - Country:US
Mailing Address - Phone:253-523-2283
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 303
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4454
Practice Address - Country:US
Practice Address - Phone:253-523-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61457617363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health