Provider Demographics
NPI:1063837144
Name:KELLEY, JACKELYN RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACKELYN
Middle Name:RAE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:RAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:141 OAK PL
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-3820
Mailing Address - Country:US
Mailing Address - Phone:724-544-3437
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:WARD 93
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:724-544-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60311101Y00000X
CA1007081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor