Provider Demographics
NPI:1992568604
Name:KELLY, JACQUELIN E (RD)
Entity type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JACQUELIN
Other - Middle Name:
Other - Last Name:NEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:694 GAMBLE OAK ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-6633
Mailing Address - Country:US
Mailing Address - Phone:480-433-7953
Mailing Address - Fax:
Practice Address - Street 1:694 GAMBLE OAK ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-6633
Practice Address - Country:US
Practice Address - Phone:480-433-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1004701133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered