Provider Demographics
NPI:1790814374
Name:KELLEY, JILL SUZANNE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:KELLEY
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 1:5003 UNA RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-1954
Mailing Address - Country:US
Mailing Address - Phone:843-307-4762
Mailing Address - Fax:843-857-4437
Practice Address - Street 1:5003 UNA RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-1954
Practice Address - Country:US
Practice Address - Phone:843-307-4762
Practice Address - Fax:843-962-5147
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6048101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC376241Medicaid