Provider Demographics
NPI:1225248248
Name:KELLY, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 TEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-3330
Mailing Address - Country:US
Mailing Address - Phone:413-754-3626
Mailing Address - Fax:
Practice Address - Street 1:139 TODDY HILL ROAD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470
Practice Address - Country:US
Practice Address - Phone:413-313-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002494225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist