Provider Demographics
NPI:1932159928
Name:KELLY, JEFFREY ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 S GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-9616
Mailing Address - Country:US
Mailing Address - Phone:989-642-5421
Mailing Address - Fax:989-792-1128
Practice Address - Street 1:4266 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-4028
Practice Address - Country:US
Practice Address - Phone:989-792-6702
Practice Address - Fax:989-792-1128
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK008789111NN1001X, 111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G30188OtherBCBS PIN
MI950G311530OtherBCBS PIN NUMBER
MIJK008789OtherBCBS LICENSE NUMBER
MI0N24830OtherMEDICARE ID
MIN24830004Medicare ID - Type UnspecifiedPROVIDER NUMBER
MI0G30188OtherBCBS PIN
MI950G311530OtherBCBS PIN NUMBER