Provider Demographics
NPI:1669971313
Name:KELLY, JASHAWN
Entity type:Individual
Prefix:
First Name:JASHAWN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 ARROTT ST FL 2F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3167
Mailing Address - Country:US
Mailing Address - Phone:267-209-0584
Mailing Address - Fax:855-489-7959
Practice Address - Street 1:1145 ARROTT ST FL 2F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3167
Practice Address - Country:US
Practice Address - Phone:267-994-2624
Practice Address - Fax:855-489-7959
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
PAPC011754101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician