Provider Demographics
NPI:1265133516
Name:KELLY, JASMINE (SWA)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:SWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4498 MANNINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-5377
Mailing Address - Country:US
Mailing Address - Phone:216-376-4330
Mailing Address - Fax:
Practice Address - Street 1:3094 W MARKET ST STE 105
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3617
Practice Address - Country:US
Practice Address - Phone:800-639-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.2100289171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty