Provider Demographics
NPI:1720168354
Name:KELLY, JILL S (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:K
Other - Last Name:SAUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:343 FRANKLIN RD STE 106
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5250
Mailing Address - Country:US
Mailing Address - Phone:615-814-4500
Mailing Address - Fax:615-814-4501
Practice Address - Street 1:343 FRANKLIN RD STE 106
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5250
Practice Address - Country:US
Practice Address - Phone:615-814-4500
Practice Address - Fax:615-814-4500
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121019208000000X
TN56893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920540OtherMEDICARE PTAN GROUP
IL036121179Medicaid
ILF400215043OtherMEDICARE PTAN INDIVIDUAL