Provider Demographics
NPI:1821751330
Name:KELLAM, JORDON KYLE (LPC)
Entity Type:Individual
Prefix:
First Name:JORDON
Middle Name:KYLE
Last Name:KELLAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:EXMORE
Mailing Address - State:VA
Mailing Address - Zip Code:23350-0591
Mailing Address - Country:US
Mailing Address - Phone:757-678-6580
Mailing Address - Fax:757-578-8231
Practice Address - Street 1:36086 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:BELLE HAVEN
Practice Address - State:VA
Practice Address - Zip Code:23306
Practice Address - Country:US
Practice Address - Phone:757-678-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010801101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional