Provider Demographics
NPI:1427877570
Name:KELLY, JACOB P
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:KELLY
Suffix:
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 1:239 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-2051
Mailing Address - Country:US
Mailing Address - Phone:330-690-3902
Mailing Address - Fax:
Practice Address - Street 1:239 1ST ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-2051
Practice Address - Country:US
Practice Address - Phone:330-690-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide