Provider Demographics
NPI:1558816702
Name:JACOBS- BELODEAU, KELLY RENEE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:JACOBS- BELODEAU
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 1:47774 BRAWNER PL
Mailing Address - Street 2:
Mailing Address - City:POTOMAC FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:20165-4708
Mailing Address - Country:US
Mailing Address - Phone:703-629-9248
Mailing Address - Fax:
Practice Address - Street 1:47774 BRAWNER PL
Practice Address - Street 2:
Practice Address - City:POTOMAC FALLS
Practice Address - State:VA
Practice Address - Zip Code:20165-4708
Practice Address - Country:US
Practice Address - Phone:703-629-9248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19679235Z00000X
VA2202004176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist