Healthcare Provider Details

I. General information

NPI: 1063460558
Provider Name (Legal Business Name): JENNIFER JO KELLY RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER JO PRICE RN, CNP

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 5006 DIABETES CLINIC
CINCINNATI OH
45229
US

IV. Provider business mailing address

3333 BURNET AVE ML 5021
CINCINNATI OH
45229-3039
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-9079
  • Fax: 513-636-7576
Mailing address:
  • Phone: 513-636-9079
  • Fax: 513-636-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.08014-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCOA.08014-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: