Healthcare Provider Details

I. General information

NPI: 1255012654
Provider Name (Legal Business Name): SHELLEY JETTE-KELLY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 BRIDGEPORT WAY W STE C2
UNIVERSITY PLACE WA
98466-4325
US

IV. Provider business mailing address

4113 BRIDGEPORT WAY W STE C2
UNIVERSITY PLACE WA
98466-4325
US

V. Phone/Fax

Practice location:
  • Phone: 253-234-4566
  • Fax: 253-276-6700
Mailing address:
  • Phone: 253-234-4566
  • Fax: 253-276-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61457617
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: