Healthcare Provider Details

I. General information

NPI: 1700160207
Provider Name (Legal Business Name): KELLEY JERRIS MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2959 SHARPSBURG MCCULLUM RD BUILDING C, SUITE C
NEWNAN GA
30265-2297
US

IV. Provider business mailing address

2959 SHARPSBURG MCCULLUM RD BUILDING C, SUITE C
NEWNAN GA
30265-2297
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-0250
  • Fax: 770-683-4250
Mailing address:
  • Phone: 770-683-0250
  • Fax: 770-683-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT005324
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: