Provider Demographics
NPI:1851722995
Name:KELLY, JENNIFER L (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 ANTHONY WAYNE TRAIL
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566
Mailing Address - Country:US
Mailing Address - Phone:419-878-3901
Mailing Address - Fax:419-878-6872
Practice Address - Street 1:555 ANTHONY WAYNE TRAIL
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566
Practice Address - Country:US
Practice Address - Phone:419-878-3901
Practice Address - Fax:419-878-6872
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP7951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist