Healthcare Provider Details

I. General information

NPI: 1407733207
Provider Name (Legal Business Name): JESSICA BONET' KELTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7825
US

IV. Provider business mailing address

4658 PRESIDENTIAL PKWY
MACON GA
31206-8708
US

V. Phone/Fax

Practice location:
  • Phone: 575-904-0959
  • Fax:
Mailing address:
  • Phone: 866-450-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: