Provider Demographics
NPI:1104490820
Name:KELLEY, JEANNINE (SLP)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:MOUNT JEWETT
Mailing Address - State:PA
Mailing Address - Zip Code:16740-0335
Mailing Address - Country:US
Mailing Address - Phone:814-558-0633
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH POINT DR
Practice Address - Street 2:
Practice Address - City:KANE
Practice Address - State:PA
Practice Address - Zip Code:16735-9704
Practice Address - Country:US
Practice Address - Phone:814-837-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSL001506235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist