Provider Demographics
NPI:1740902840
Name:DEBOE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEBOE
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 1:10944 MILNES RD
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49250-9827
Mailing Address - Country:US
Mailing Address - Phone:517-877-2355
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-416-1835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6852093506171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator