MEDICARE: JENNA MICHELLE KELSON O.D.

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	152W00000X	Optometrist	008478	NY

General Provider Information

NPI Number	:	1821449174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA MICHELLE KELSON O.D.

Provider Business Mailing Address
First Line	:	894 MEINECKE AVE
Second Line	:	STE A
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-1790
Country	:	US
Telephone Number	:	805-543-6632
Fax Number	:

Provider Business Practice Location Address
First Line	:	2133 86TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-3205
Country	:	US
Telephone Number	:	718-449-1525
Fax Number	:

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

Provider Enumeration Date	:	06/28/2016
Last Update Date	:	09/19/2019

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