Provider Demographics
NPI:1518305531
Name:KELLEY, JANE MARIE (LAC)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 FRONTAGE RD NW
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1621
Mailing Address - Country:US
Mailing Address - Phone:507-216-1793
Mailing Address - Fax:
Practice Address - Street 1:501 FRONTAGE RD NW
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920-1621
Practice Address - Country:US
Practice Address - Phone:507-216-1793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist