Provider Demographics
NPI:1033695606
Name:JAKSA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JAKSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2179 FOX HILL DR APT 11
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5232
Mailing Address - Country:US
Mailing Address - Phone:989-854-0255
Mailing Address - Fax:
Practice Address - Street 1:1085 S LINDEN RD STE 100
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3416
Practice Address - Country:US
Practice Address - Phone:810-262-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005864235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist