Provider Demographics
NPI:1962770008
Name:KELLY, JEANNE MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8829 155TH AVE
Mailing Address - Street 2:APT. 4H
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2139
Mailing Address - Country:US
Mailing Address - Phone:718-738-6522
Mailing Address - Fax:
Practice Address - Street 1:8829 155TH AVE
Practice Address - Street 2:APT. 4H
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2139
Practice Address - Country:US
Practice Address - Phone:718-738-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011270-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist