Provider Demographics
NPI:1366179509
Name:KELLING, JADE ALEXIS
Entity type:Individual
Prefix:MISS
First Name:JADE
Middle Name:ALEXIS
Last Name:KELLING
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 1256
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-1256
Mailing Address - Country:US
Mailing Address - Phone:701-444-2888
Mailing Address - Fax:701-444-2813
Practice Address - Street 1:340 N MAIN ST STE 311
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7308
Practice Address - Country:US
Practice Address - Phone:701-444-2888
Practice Address - Fax:701-444-2813
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDF08220262207Q00000X, 363LF0000X
NDR43520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine