=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942569959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LYNN KELLY D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2012
-----------------------------------------------------
Last Update Date | 12/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S MAIN ST
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-8481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-738-2100
-----------------------------------------------------
Fax | 219-933-2288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 RANDALL RD
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60134-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-933-4700
-----------------------------------------------------
Fax | 630-933-4427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 02006177A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036.137522
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 036.137522
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------