Provider Demographics
NPI:1326455924
Name:KELLETT, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:KELLETT
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 1:3605 E COUNTY HIGHWAY 30A
Mailing Address - Street 2:#142
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-6478
Mailing Address - Country:US
Mailing Address - Phone:928-308-4088
Mailing Address - Fax:
Practice Address - Street 1:3605 E COUNTY HIGHWAY 30A
Practice Address - Street 2:#142
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-6478
Practice Address - Country:US
Practice Address - Phone:928-308-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker