Provider Demographics
NPI:1033302872
Name:JENNIFER M. KELLY, LCSW LLC
Entity Type:Organization
Organization Name:JENNIFER M. KELLY, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-660-6846
Mailing Address - Street 1:11330 Q ST
Mailing Address - Street 2:SUITE 222
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11330 Q ST
Practice Address - Street 2:SUITE 222
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3679
Practice Address - Country:US
Practice Address - Phone:402-660-6846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE997251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========26Medicaid
NE274697Medicare PIN