Healthcare Provider Details

I. General information

NPI: 1962804880
Provider Name (Legal Business Name): JENNIFER KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3841 RUCKRIEGEL PKWY
LOUISVILLE KY
40299-3986
US

IV. Provider business mailing address

600 CROSS POINTE RD SUITE A
GAHANNA OH
43230-6696
US

V. Phone/Fax

Practice location:
  • Phone: 502-791-8700
  • Fax: 502-742-8523
Mailing address:
  • Phone: 513-725-2186
  • Fax: 614-577-1427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number3008785
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3008785
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: