Provider Demographics
NPI:1528048667
Name:KELLY-MCCOY, JENNIFER L (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KELLY-MCCOY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:KELLY
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:4755 OGLETOWN STANTON RD STE 2E99
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-5982
Mailing Address - Fax:302-733-6081
Practice Address - Street 1:4755 OGLETOWN STANTON ROAD
Practice Address - Street 2:SUITE 2E99
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-5982
Practice Address - Fax:302-733-6081
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S75006Medicare UPIN
MDAO25Medicare ID - Type Unspecified
MD3431Medicare ID - Type Unspecified