Provider Demographics
NPI:1669364782
Name:KELLEY, JENNIFER MARILYNN (DNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARILYNN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-3458
Mailing Address - Country:US
Mailing Address - Phone:650-402-9731
Mailing Address - Fax:
Practice Address - Street 1:2001 DWIGHT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-1591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95036322363LP2300X, 363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health