Provider Demographics
NPI:1023714409
Name:JACQUELYN KELLOGG, LLC
Entity type:Organization
Organization Name:JACQUELYN KELLOGG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLP
Authorized Official - Phone:616-340-1061
Mailing Address - Street 1:6018 CORNERSTONE CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418
Mailing Address - Country:US
Mailing Address - Phone:616-340-1061
Mailing Address - Fax:
Practice Address - Street 1:6018 CORNERSTONE CT SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-340-1061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty