Provider Demographics
NPI:1437126679
Name:KELLY, JACLYN KRISTEN (ATC)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:KRISTEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 N AIRLITE ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2675
Mailing Address - Country:US
Mailing Address - Phone:847-741-7439
Mailing Address - Fax:
Practice Address - Street 1:2211 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1570
Practice Address - Country:US
Practice Address - Phone:847-267-8600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer