Provider Demographics
NPI:1144822263
Name:KELLY, JENNIFER DENISE (RPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 JENNY WREN ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-2526
Mailing Address - Country:US
Mailing Address - Phone:479-806-6380
Mailing Address - Fax:
Practice Address - Street 1:2100 N 62ND ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5163
Practice Address - Country:US
Practice Address - Phone:479-782-0606
Practice Address - Fax:479-783-2206
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist