Provider Demographics
NPI:1235400540
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 1:4828 HARBOR OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1944
Mailing Address - Country:US
Mailing Address - Phone:757-450-3421
Mailing Address - Fax:
Practice Address - Street 1:4828 HARBOR OAKS WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-1944
Practice Address - Country:US
Practice Address - Phone:305-846-9807
Practice Address - Fax:305-846-9711
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst