Provider Demographics
NPI:1033004619
Name:KELLY, JAMIE LYNN (SUDP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 31ST AVE NE STE 101
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-7423
Mailing Address - Country:US
Mailing Address - Phone:425-330-1660
Mailing Address - Fax:
Practice Address - Street 1:6330 31ST AVE NE STE 191
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-7423
Practice Address - Country:US
Practice Address - Phone:360-716-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60887509101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)