Provider Demographics
NPI:1396914388
Name:KELLY, JENNIFER LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:DEBUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1039 WASHINGTON ST
Mailing Address - Street 2:STE 2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2016
Mailing Address - Country:US
Mailing Address - Phone:734-260-1895
Mailing Address - Fax:313-724-8926
Practice Address - Street 1:8240 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1435
Practice Address - Country:US
Practice Address - Phone:313-724-8638
Practice Address - Fax:313-724-8926
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor