Provider Demographics
NPI:1093520736
Name:JELLEY, KIMBERLY A (LMSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JELLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1447
Mailing Address - Country:US
Mailing Address - Phone:631-384-3882
Mailing Address - Fax:
Practice Address - Street 1:4424 WILSHIRE LN
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1447
Practice Address - Country:US
Practice Address - Phone:631-384-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092546104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker