Basic Information
Provider Information | |||||||||
NPI: | 1851551949 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | PATRICK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3841 PIPER ST SUITE T100 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 99508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075613211 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3841 PIPER ST STE T100 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995084674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075613211 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2008 | ||||||||
LastUpdateDate: | 02/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N5767 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 2012-01069 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 119045 | AK | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 390200000X | 2012-01069 | NC | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RA0001X | 119045 | AK | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 1668479 | 05 | AK |   | MEDICAID | 1851551949 | 05 | NC |   | MEDICAID |