Provider Demographics
NPI:1669043048
Name:KELLY, JAMIE NICHOLE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:NICHOLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 S NORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-7118
Mailing Address - Country:US
Mailing Address - Phone:812-413-9321
Mailing Address - Fax:
Practice Address - Street 1:315 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6743
Practice Address - Country:US
Practice Address - Phone:812-413-9321
Practice Address - Fax:812-413-9323
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-51223103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst