Provider Demographics
NPI:1164776241
Name:KELLEY, JONATHAN (LMHC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02660-2538
Mailing Address - Country:US
Mailing Address - Phone:508-292-0983
Mailing Address - Fax:
Practice Address - Street 1:1581 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4602
Practice Address - Country:US
Practice Address - Phone:508-292-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health