Provider Demographics
NPI:1528095460
Name:KELLY, JERALD DONALD (DC)
Entity type:Individual
Prefix:DR
First Name:JERALD
Middle Name:DONALD
Last Name:KELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 DOCTOR CIR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5050
Mailing Address - Country:US
Mailing Address - Phone:903-753-2322
Mailing Address - Fax:903-234-2322
Practice Address - Street 1:2 DOCTOR CIR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5050
Practice Address - Country:US
Practice Address - Phone:903-753-2322
Practice Address - Fax:903-234-2979
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB147421Medicare PIN