Provider Demographics
NPI:1750810776
Name:BOOTH, KELLY JO
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:BOOTH
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 1:81 GLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-9730
Mailing Address - Country:US
Mailing Address - Phone:360-461-7511
Mailing Address - Fax:
Practice Address - Street 1:914 WASHINGTON ST STE 7
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-5746
Practice Address - Country:US
Practice Address - Phone:360-643-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician