Provider Demographics
NPI:1306531124
Name:KELLY, JEANETTE ANN (LPC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SANDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8502
Mailing Address - Country:US
Mailing Address - Phone:609-668-1186
Mailing Address - Fax:
Practice Address - Street 1:114 5TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-5611
Practice Address - Country:US
Practice Address - Phone:609-668-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00931100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional