Provider Demographics
NPI:1396461083
Name:KELLY, JORDAN DENISE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DENISE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 WOODBURY ST APT 710
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-6732
Mailing Address - Country:US
Mailing Address - Phone:315-663-5436
Mailing Address - Fax:
Practice Address - Street 1:7 RIVERWOODS DR
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-4374
Practice Address - Country:US
Practice Address - Phone:603-772-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5056208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation