Healthcare Provider Details

I. General information

NPI: 1255865895
Provider Name (Legal Business Name): KELLY ANNE JENKINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANNE HARMS MD

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2933 BRECKENRIDGE LN STE 103
LOUISVILLE KY
40220-1494
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 502-394-5678
  • Fax: 502-394-5600
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351029354
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35.145052
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number58034
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: