MEDICARE: JALISSA C KELLY PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	31456	SC

General Provider Information

NPI Number	:	1265381800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JALISSA C KELLY PMHNP

Provider Business Mailing Address
First Line	:	1901 MAIN ST FL 18
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-2435
Country	:	US
Telephone Number	:	839-207-0558
Fax Number	:	839-207-0558

Provider Business Practice Location Address
First Line	:	1901 MAIN ST FL 18
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-2435
Country	:	US
Telephone Number	:	839-207-0558
Fax Number	:	839-207-0558

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	06/10/2026

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