Basic Information
| Provider Information | |||||||||
| NPI: | 1659547503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | KELLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 W. HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708862205 | ||||||||
| FaxNumber: | 2708862205 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 W. HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708862205 | ||||||||
| FaxNumber: | 2708860392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 3571 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 30602015 | 05 | KY | MEDICAID |