Healthcare Provider Details

I. General information

NPI: 1396383030
Provider Name (Legal Business Name): JACK KELLY BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 SHERWOOD DR STE 201
LAKE BLUFF IL
60044-2235
US

IV. Provider business mailing address

426 W BELMONT AVE APT 807
CHICAGO IL
60657-4721
US

V. Phone/Fax

Practice location:
  • Phone: 877-486-4140
  • Fax:
Mailing address:
  • Phone: 773-386-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-45283
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: