Provider Demographics
NPI:1932327756
Name:KELLEY, JACQUELYN A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6804 WILD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7467
Mailing Address - Country:US
Mailing Address - Phone:469-667-9413
Mailing Address - Fax:469-384-4922
Practice Address - Street 1:2419 COIT RD STE C
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-3731
Practice Address - Country:US
Practice Address - Phone:469-667-9413
Practice Address - Fax:469-384-4922
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX381341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical