Provider Demographics
NPI:1427108653
Name:KELLEY, JONATHAN R (DMIN, LPC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DMIN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 WRIGHTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6917
Mailing Address - Country:US
Mailing Address - Phone:910-452-7370
Mailing Address - Fax:910-798-5199
Practice Address - Street 1:4810 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6917
Practice Address - Country:US
Practice Address - Phone:910-452-7370
Practice Address - Fax:910-798-5199
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5550101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor