Provider Demographics
NPI:1750164935
Name:KELLEY, CAROLINE JOANNA
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:JOANNA
Last Name:KELLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LOUIE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-9334
Mailing Address - Country:US
Mailing Address - Phone:850-509-1381
Mailing Address - Fax:
Practice Address - Street 1:1368 PINEY GREEN RD STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-4577
Practice Address - Country:US
Practice Address - Phone:910-333-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2712106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst