Provider Demographics
NPI:1861505620
Name:KELLY, JENNIFER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E BROAD ST
Mailing Address - Street 2:SUITE J
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501
Mailing Address - Country:US
Mailing Address - Phone:931-520-0736
Mailing Address - Fax:931-520-0743
Practice Address - Street 1:441 E BROAD ST
Practice Address - Street 2:SUITE J
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-520-0736
Practice Address - Fax:931-520-0743
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW 0000004162104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3926505Medicaid
TN4069908OtherBLUE CROSS
TN3926505Medicaid