Provider Demographics
NPI:1093740862
Name:KELLOGG, JEFFREY SAUNDERS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SAUNDERS
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-8362
Mailing Address - Country:US
Mailing Address - Phone:618-457-4488
Mailing Address - Fax:618-457-8844
Practice Address - Street 1:3412 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62903-8362
Practice Address - Country:US
Practice Address - Phone:618-457-4488
Practice Address - Fax:618-457-8844
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003739103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical