Provider Demographics
NPI:1144897596
Name:KELLY, JESSICA ELLEN (ARNP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELLEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7918 SE YOSEMITE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367
Mailing Address - Country:US
Mailing Address - Phone:253-720-7998
Mailing Address - Fax:
Practice Address - Street 1:2420 S STATE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2845
Practice Address - Country:US
Practice Address - Phone:253-573-6113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61185982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily