Basic Information
| Provider Information | |||||||||
| NPI: | 1396383030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 W BELMONT AVE APT 807 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733864024 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 917 SHERWOOD DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 103K00000X | 1-20-45283 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.