Provider Demographics
NPI:1932245339
Name:KELLEY, KAREN A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:K
Other - Last Name:COSTLOW-NOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:10991 SAN JOSE BLVD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-6675
Mailing Address - Country:US
Mailing Address - Phone:229-444-0302
Mailing Address - Fax:
Practice Address - Street 1:10991 SAN JOSE BLVD UNIT 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6675
Practice Address - Country:US
Practice Address - Phone:904-380-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0040801041C0700X
FLSW131801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA842889733BMedicaid
GA842889733CMedicaid
GA842889733CMedicaid