Healthcare Provider Details

I. General information

NPI: 1568706141
Provider Name (Legal Business Name): OPHELIA KELLY L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OPHELIA KELLY L.S.W.

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 TERRY RD
JACKSON MS
39212-3073
US

IV. Provider business mailing address

105 MEADOWVIEW CIR
CLINTON MS
39056-5907
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-0566
  • Fax: 601-373-0566
Mailing address:
  • Phone: 601-608-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberW0803
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1820
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: