Provider Demographics
NPI:1205181971
Name:JANSON, KELLY A (LISW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:JANSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1711
Mailing Address - Country:US
Mailing Address - Phone:513-751-7747
Mailing Address - Fax:513-751-0180
Practice Address - Street 1:8735 CINCINNATI DAYTON RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3136
Practice Address - Country:US
Practice Address - Phone:513-785-6900
Practice Address - Fax:513-751-0180
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.30901031104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0186479Medicaid