Provider Demographics
NPI:1104406990
Name:KELLEY, JEFFERY JEANE JR
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:JEANE
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ASHLEY PL APT 2
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3541
Mailing Address - Country:US
Mailing Address - Phone:618-910-0942
Mailing Address - Fax:
Practice Address - Street 1:205 ASHLEY PL APT 2
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3541
Practice Address - Country:US
Practice Address - Phone:618-910-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide