Provider Demographics
NPI:1881205920
Name:KELLAM, JAWAAN
Entity Type:Individual
Prefix:MR
First Name:JAWAAN
Middle Name:
Last Name:KELLAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CATAWBA ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1825
Mailing Address - Country:US
Mailing Address - Phone:315-559-6303
Mailing Address - Fax:
Practice Address - Street 1:42 CATAWBA ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-1825
Practice Address - Country:US
Practice Address - Phone:315-559-6303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker