Healthcare Provider Details

I. General information

NPI: 1205190766
Provider Name (Legal Business Name): JAMI R KELLY R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 J ST
OMAHA NE
68107-1643
US

IV. Provider business mailing address

3017 10TH AVE
COUNCIL BLUFFS IA
51501-5844
US

V. Phone/Fax

Practice location:
  • Phone: 402-733-1325
  • Fax: 402-734-1780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2106
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number03710
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: