Provider Demographics
NPI:1558688242
Name:KELLY, JODEY LYNN
Entity Type:Individual
Prefix:MRS
First Name:JODEY
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODEY
Other - Middle Name:LYNN
Other - Last Name:PEDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 E WILL ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-7452
Mailing Address - Country:US
Mailing Address - Phone:918-283-2002
Mailing Address - Fax:
Practice Address - Street 1:201 E WILL ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-7452
Practice Address - Country:US
Practice Address - Phone:918-283-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor