Healthcare Provider Details

I. General information

NPI: 1497215248
Provider Name (Legal Business Name): JARED ROBERT KELLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 10/26/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MOCKSVILLE AVE
SALISBURY NC
28144-2732
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 818-391-7794
  • Fax:
Mailing address:
  • Phone: 704-210-5061
  • Fax: 704-210-5337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0010-08856
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0010-08856
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number0010-08856
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: