Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | H4611 | OR |
NPI | 1033363213 |
---|---|
Provider Name | Mrs. Jessica Ann Kelly |
First Address | Damascus, OR 97089-9130 |
Second Address | Lake Oswego, OR 97034-3956 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2008 |
Last Update Date | 13/11/2008 |