Provider Demographics
NPI:1700637774
Name:KELLEY, JENNIFER LEE (CNS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8563 BERGIN RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9032
Mailing Address - Country:US
Mailing Address - Phone:734-936-8058
Mailing Address - Fax:
Practice Address - Street 1:1540 E HOSPITAL DR SPC 4242
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4242
Practice Address - Country:US
Practice Address - Phone:734-936-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287974364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics