Provider Demographics
NPI:1962804880
Name:KELLY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CROSS POINTE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6696
Mailing Address - Country:US
Mailing Address - Phone:513-725-2186
Mailing Address - Fax:614-577-1427
Practice Address - Street 1:3841 RUCKRIEGEL PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-3986
Practice Address - Country:US
Practice Address - Phone:502-791-8700
Practice Address - Fax:502-742-8523
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008785363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100365330Medicaid
KYK179990Medicare PIN