Provider Demographics
NPI:1235963885
Name:KELLY, JOLENE (LMT)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 CHAFFEE CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-2309
Mailing Address - Country:US
Mailing Address - Phone:907-360-2215
Mailing Address - Fax:
Practice Address - Street 1:6711 DEBARR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1803
Practice Address - Country:US
Practice Address - Phone:907-333-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK214003225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist