Provider Demographics
NPI:1659989770
Name:KELLY, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 LEHIGH DR
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1616
Mailing Address - Country:US
Mailing Address - Phone:732-768-4684
Mailing Address - Fax:
Practice Address - Street 1:281 STATE ROUTE 79 N
Practice Address - Street 2:
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1157
Practice Address - Country:US
Practice Address - Phone:732-768-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00527400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ913134183OtherUNITED HEALTHCARE