Provider Demographics
NPI:1043807654
Name:BADGETT, JOHN KELLY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KELLY
Last Name:BADGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5049
Mailing Address - Country:US
Mailing Address - Phone:707-640-4281
Mailing Address - Fax:
Practice Address - Street 1:1525 UNION AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5049
Practice Address - Country:US
Practice Address - Phone:707-640-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA178015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)