Provider Demographics
NPI:1164692455
Name:MACK, KELLY JENE (BS, CADCI)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JENE
Last Name:MACK
Suffix:
Gender:F
Credentials:BS, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 PORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0311
Mailing Address - Country:US
Mailing Address - Phone:503-390-2600
Mailing Address - Fax:
Practice Address - Street 1:3737 PORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0311
Practice Address - Country:US
Practice Address - Phone:503-390-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05-11-34101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)