Provider Demographics
NPI:1326400797
Name:KELLETT, JACQUELYN (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:KELLETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-1307
Mailing Address - Country:US
Mailing Address - Phone:504-952-3658
Mailing Address - Fax:
Practice Address - Street 1:1855 AMES BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3429
Practice Address - Country:US
Practice Address - Phone:504-214-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA116161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical