Provider Demographics
NPI:1093125650
Name:KELL, JACQUELYNNE
Entity Type:Individual
Prefix:
First Name:JACQUELYNNE
Middle Name:
Last Name:KELL
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 1:16220 FREDERICK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-4039
Mailing Address - Country:US
Mailing Address - Phone:301-345-1022
Mailing Address - Fax:
Practice Address - Street 1:629 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2045
Practice Address - Country:US
Practice Address - Phone:417-409-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015044822101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor