Healthcare Provider Details

I. General information

NPI: 1437126679
Provider Name (Legal Business Name): JACLYN KRISTEN KELLY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 WAUKEGAN RD
BANNOCKBURN IL
60015-1570
US

IV. Provider business mailing address

648 N AIRLITE ST
ELGIN IL
60123-2675
US

V. Phone/Fax

Practice location:
  • Phone: 847-267-8600
  • Fax:
Mailing address:
  • Phone: 847-741-7439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: