Provider Demographics
NPI:1164163887
Name:KELLY, JESSICA MARIE (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:MCRAE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4 ALLEGHENY CTR FL 7
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 GALLERY DR
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2690
Practice Address - Country:US
Practice Address - Phone:412-831-8089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016994207Q00000X
390200000X
PAOS024767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484698Medicaid