Provider Demographics
NPI:1689680860
Name:KELLEY, JANE ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:ANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3014
Mailing Address - Country:US
Mailing Address - Phone:414-271-9272
Mailing Address - Fax:414-271-1299
Practice Address - Street 1:1216 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3014
Practice Address - Country:US
Practice Address - Phone:414-271-9272
Practice Address - Fax:414-271-1299
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI598-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391959004014OtherBLUE CROSS BLUE SHIELD
WI391959004014OtherBLUE CROSS BLUE SHIELD
WIP27299Medicare UPIN