Provider Demographics
NPI:1710293436
Name:KELLY, JACQUELINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 SUMMERFORD CT NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7712
Mailing Address - Country:US
Mailing Address - Phone:704-467-3730
Mailing Address - Fax:
Practice Address - Street 1:220 GEORGE W LILES PKWY NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-6531
Practice Address - Country:US
Practice Address - Phone:704-795-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist