Provider Demographics
NPI:1801497615
Name:KELLEY, JENNA (MS, LPC, ATR)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 CERALENE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1703
Mailing Address - Country:US
Mailing Address - Phone:757-802-2221
Mailing Address - Fax:
Practice Address - Street 1:8500 EXECUTIVE PARK AVE STE 202
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2253
Practice Address - Country:US
Practice Address - Phone:703-852-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional