Provider Demographics
NPI:1295696714
Name:KELLY, JEREMY JOHN
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LONG POND RD STE 222
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-1177
Mailing Address - Country:US
Mailing Address - Phone:585-385-6030
Mailing Address - Fax:
Practice Address - Street 1:1100 LONG POND RD STE 222
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1177
Practice Address - Country:US
Practice Address - Phone:585-385-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor