Provider Demographics
NPI:1528656121
Name:KELLY, JENNIFER (PD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PD
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:HAZEN
Mailing Address - State:AR
Mailing Address - Zip Code:72064-0507
Mailing Address - Country:US
Mailing Address - Phone:870-255-3433
Mailing Address - Fax:870-255-3772
Practice Address - Street 1:202 SOUTH LIVERMORE
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:AR
Practice Address - Zip Code:72064
Practice Address - Country:US
Practice Address - Phone:870-255-4403
Practice Address - Fax:870-255-3772
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1477688463Other1477688463