Provider Demographics
NPI:1114312303
Name:KELLEY-KINYON, JAMIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:M
Last Name:KELLEY-KINYON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:M
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-8740
Mailing Address - Fax:208-814-8955
Practice Address - Street 1:775 POLE LINE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-814-8740
Practice Address - Fax:208-814-8955
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1041C0700X
IDLCSW 4971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical