Provider Demographics
NPI:1649475765
Name:DONNELL-JACKSON, KELLY L (RN, MSN, APN-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DONNELL-JACKSON
Suffix:
Gender:F
Credentials:RN, MSN, APN-C
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1015 BRIGGS RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-4115
Practice Address - Country:US
Practice Address - Phone:856-727-0900
Practice Address - Fax:856-231-8428
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NR09192400163W00000X
PASP010454363L00000X
NJ26NJ00060400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123008XVAMedicare UPIN