Provider Demographics
NPI:1669631065
Name:KELLY, JEFF (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 LAKE EARL DR
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95532-0001
Mailing Address - Country:US
Mailing Address - Phone:707-465-1000
Mailing Address - Fax:
Practice Address - Street 1:1080 MASON MALL STE 6C
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4335
Practice Address - Country:US
Practice Address - Phone:707-951-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20204103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist