Provider Demographics
NPI:1508922105
Name:KELLY, JENNIFER FAYE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:FAYE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3280 HOWELL MILL RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4111
Mailing Address - Country:US
Mailing Address - Phone:404-351-6789
Mailing Address - Fax:404-351-2932
Practice Address - Street 1:3280 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4111
Practice Address - Country:US
Practice Address - Phone:404-351-6789
Practice Address - Fax:404-351-2932
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00471732BMedicaid
GA68BBCWTMedicare ID - Type Unspecified