Provider Demographics
NPI:1699774505
Name:KELLY, JACQUELINE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-2104
Mailing Address - Country:US
Mailing Address - Phone:512-587-0065
Mailing Address - Fax:512-469-7854
Practice Address - Street 1:300 E 8TH ST
Practice Address - Street 2:G-159
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-3233
Practice Address - Country:US
Practice Address - Phone:512-587-0065
Practice Address - Fax:512-469-7854
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6266208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice