Healthcare Provider Details

I. General information

NPI: 1750694337
Provider Name (Legal Business Name): KELLEY JEAN VICTOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E RIVER DR STE 303
DAVENPORT IA
52803-5752
US

IV. Provider business mailing address

3 COBBLESTONE LN
LE CLAIRE IA
52753-9249
US

V. Phone/Fax

Practice location:
  • Phone: 563-265-2722
  • Fax:
Mailing address:
  • Phone: 319-321-4279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD47704
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD448207
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: