Provider Demographics
NPI:1154016301
Name:KELLY, JALISA MARIE
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:MARIE
Last Name:KELLY
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 1:4001 S CAPITOL ST SW APT 207
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1373
Mailing Address - Country:US
Mailing Address - Phone:202-491-7689
Mailing Address - Fax:
Practice Address - Street 1:4001 S CAPITOL ST SW APT 129
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1368
Practice Address - Country:US
Practice Address - Phone:202-230-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC00000374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide