Provider Demographics
NPI:1912103656
Name:KELLY, JENNIFER ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HUTCHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2846 ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2674
Mailing Address - Country:US
Mailing Address - Phone:618-709-0010
Mailing Address - Fax:618-397-4503
Practice Address - Street 1:2846 ROBERT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2674
Practice Address - Country:US
Practice Address - Phone:618-709-0010
Practice Address - Fax:618-397-4503
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490120431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical