Provider Demographics
NPI:1619792496
Name:KELLEY, SHAWN CHRISTOPHER JR
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHRISTOPHER
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 SW HIGHLAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2558
Mailing Address - Country:US
Mailing Address - Phone:541-923-2654
Mailing Address - Fax:
Practice Address - Street 1:1655 SW HIGHLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2558
Practice Address - Country:US
Practice Address - Phone:541-923-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-CRM-3836175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist