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NPI Code Detail

MEDICARE: KENNETH JASON KELLY PT, DPT

MEDICARE: KENNETH JASON KELLY PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist2305206555VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1192946OTHERVABCBS (PHYSICAL THERAPY)
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
39631527OTHERVAAETNA

General Provider Information

NPI Number : 1821301961
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH JASON KELLY PT, DPT
Provider Business Mailing Address
First Line : 350 NEW FIDELITY CT
Second Line :
City : GARNER
State : NC
Zip : 27529-2665
Country : US
Telephone Number : 919-258-2714
Fax Number : 410-648-4878
Provider Business Practice Location Address
First Line : 300B TEMPLE LAKE DR STE 1
Second Line :
City : COLONIAL HEIGHTS
State : VA
Zip : 23834-2973
Country : US
Telephone Number : 804-524-9036
Fax Number : 804-524-9039
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2010
Last Update Date : 05/27/2020

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