Provider Demographics
NPI:1063816726
Name:KELLEY, JESSICA (MA, LLPC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:NOVETSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:837 FERN ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3409
Mailing Address - Country:US
Mailing Address - Phone:517-588-1136
Mailing Address - Fax:
Practice Address - Street 1:720 WAYNE ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-1493
Practice Address - Country:US
Practice Address - Phone:231-714-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health