Provider Demographics
NPI:1225183056
Name:KELSO, JEANNIE N (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANNIE
Middle Name:N
Last Name:KELSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JEAN
Other - Middle Name:N
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1514 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2129
Mailing Address - Country:US
Mailing Address - Phone:601-398-0989
Mailing Address - Fax:
Practice Address - Street 1:1059 RIDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2018
Practice Address - Country:US
Practice Address - Phone:601-957-3211
Practice Address - Fax:601-957-9753
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC7281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid
MSPENDINGMedicare ID - Type UnspecifiedPENDING
MSPENDINGMedicaid