Healthcare Provider Details

I. General information

NPI: 1043588551
Provider Name (Legal Business Name): KELLY JAYNE KALK D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SE DOWSETT LN
GRESHAM OR
97080-7816
US

IV. Provider business mailing address

700 SE DOWSETT LN
GRESHAM OR
97080-7816
US

V. Phone/Fax

Practice location:
  • Phone: 503-936-5098
  • Fax:
Mailing address:
  • Phone: 503-936-5098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5012
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: