Provider Demographics
NPI:1124619390
Name:KELLEY, JON GARRICK (COTA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:GARRICK
Last Name:KELLEY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:DODGE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55927-9172
Mailing Address - Country:US
Mailing Address - Phone:507-635-6415
Mailing Address - Fax:
Practice Address - Street 1:702 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:DODGE CENTER
Practice Address - State:MN
Practice Address - Zip Code:55927-9172
Practice Address - Country:US
Practice Address - Phone:507-635-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201600224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant