Provider Demographics
NPI:1609279454
Name:KELLY, JANAYA GRACE (CADC II)
Entity Type:Individual
Prefix:
First Name:JANAYA
Middle Name:GRACE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 E ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3511
Mailing Address - Country:US
Mailing Address - Phone:530-848-0932
Mailing Address - Fax:916-446-4939
Practice Address - Street 1:500 22ND ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3503
Practice Address - Country:US
Practice Address - Phone:916-442-4519
Practice Address - Fax:916-446-4939
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-145596101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0393743OtherNON PROFIT