Provider Demographics
NPI:1962665729
Name:KELLY, JANA
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:KELLY
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 1:139 SCOTTLAND LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:AR
Mailing Address - Zip Code:71929-7271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 LAKESHORE ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:AR
Practice Address - Zip Code:71943-9127
Practice Address - Country:US
Practice Address - Phone:870-356-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131122721Medicaid