Provider Demographics
NPI:1063428100
Name:KELLEY, JANE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14397
Mailing Address - Street 2:SUITE 101
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-7397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 ENCLAVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-3207
Practice Address - Country:US
Practice Address - Phone:724-598-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009170L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00770539OtherMEDICARE TRAVELERS
PA0015972070007Medicaid
PA881405OtherBLUE SHIELD
PAP00770539OtherMEDICARE TRAVELERS
PA0015972070007Medicaid