Provider Demographics
NPI:1750744488
Name:KELLEY, JENNA (MS, RD, CD)
Entity type:Individual
Prefix:MS
First Name:JENNA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 VIRGINIA ST UNIT 2504
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-4429
Mailing Address - Country:US
Mailing Address - Phone:262-951-8443
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4048133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric