| Doctor Name: | JERRY KELLY |
| NPI Number: | 1043611783 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | E3038628 |
| Business Practice Address: | 1061 Harmon Ave Fort Stewart, GA - 313145641 |
| Business Phone Number: | 9124355211 |
| Business Fax Number: | |
| Mailing Address: | 1061 Harmon Ave, FORT STEWART |
| State: | GA |
| Postal Code: | 313145641 |
| Phone Number: | 9124355211 |
| Fax Number: | |
| NPI Enumeration Date: | 09/12/2014 |
| NPI Last Update Date: | 09/12/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | E3038628 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |