Provider Demographics
NPI:1518580174
Name:KELLY, JESSIE (LMFT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 BRAINERD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-2709
Mailing Address - Country:US
Mailing Address - Phone:423-788-8059
Mailing Address - Fax:
Practice Address - Street 1:3505 BRAINERD RD STE 1
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-2709
Practice Address - Country:US
Practice Address - Phone:423-788-8059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist