Provider Demographics
NPI:1114762655
Name:JEWELL, KELLIE JODY
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JODY
Last Name:JEWELL
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 1:5510 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-9346
Mailing Address - Country:US
Mailing Address - Phone:937-733-4954
Mailing Address - Fax:
Practice Address - Street 1:5510 WEAVER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:OH
Practice Address - Zip Code:45327-9346
Practice Address - Country:US
Practice Address - Phone:937-733-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide