Provider Demographics
NPI:1649057399
Name:KELP, JACOB RYAN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:KELP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3303
Mailing Address - Country:US
Mailing Address - Phone:360-261-0128
Mailing Address - Fax:
Practice Address - Street 1:11104 NE 149TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9565
Practice Address - Country:US
Practice Address - Phone:360-885-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist