Provider Demographics
NPI:1972049450
Name:PICKERING, KELLY JEAN (LPC, CMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:PICKERING
Suffix:
Gender:F
Credentials:LPC, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 N 300 E
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1530
Mailing Address - Country:US
Mailing Address - Phone:801-823-4411
Mailing Address - Fax:
Practice Address - Street 1:146 W 300 S STE 104
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6250
Practice Address - Country:US
Practice Address - Phone:801-823-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
UT11739145-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health