Healthcare Provider Details

I. General information

NPI: 1366760993
Provider Name (Legal Business Name): JENNIFER KELLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5751 SHED RD STE 120
BOSSIER CITY LA
71111-5662
US

IV. Provider business mailing address

5751 SHED RD STE 120
BOSSIER CITY LA
71111-5662
US

V. Phone/Fax

Practice location:
  • Phone: 318-935-1922
  • Fax: 318-935-1925
Mailing address:
  • Phone: 318-935-1922
  • Fax: 318-935-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.206814
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.206814
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: