Provider Demographics
NPI:1356039390
Name:KELLY HALL, JACQUELYN MICHELLE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:KELLY HALL
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 1:517 S 64TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2664
Mailing Address - Country:US
Mailing Address - Phone:714-430-0157
Mailing Address - Fax:
Practice Address - Street 1:517 S 64TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2664
Practice Address - Country:US
Practice Address - Phone:714-430-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator