Provider Demographics
NPI:1790121614
Name:JAMESON, KELLY JEAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:JAMESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 ROBY LN
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-9550
Mailing Address - Country:US
Mailing Address - Phone:270-256-9211
Mailing Address - Fax:
Practice Address - Street 1:361 ROBY LN
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:KY
Practice Address - Zip Code:42347-9550
Practice Address - Country:US
Practice Address - Phone:270-256-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-18
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist