Basic Information
| Provider Information | |||||||||
| NPI: | 1881802627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036921242 | ||||||||
| FaxNumber: | 5036913615 | ||||||||
| Practice Location | |||||||||
| Address1: | 19250 SW 65TH AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970627452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036921242 | ||||||||
| FaxNumber: | 5036913615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 06/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD 27685 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | R157973 | 01 | OR | MEDICARE PTAN | OTHER | 500623446 | 05 | OR | MEDICAID |