Provider Demographics
NPI:1396383030
Name:KELLY, JACK (BCBA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 W BELMONT AVE APT 807
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4721
Mailing Address - Country:US
Mailing Address - Phone:773-386-4024
Mailing Address - Fax:
Practice Address - Street 1:917 SHERWOOD DR STE 201
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2235
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
IL1-20-45283103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst