Provider Demographics
NPI:1194223156
Name:KELLEY HAQUE, JENNA LYNN (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:KELLEY HAQUE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LYNN
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11508 FALLING LEAVES DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-9129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 SCALEYBARK RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2682
Practice Address - Country:US
Practice Address - Phone:704-717-2809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12059A106H00000X
NC2149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist