Healthcare Provider Details

I. General information

NPI: 1447163449
Provider Name (Legal Business Name): KELLY LEE JACKSON M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY LEE DURANN

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 GREENWICH DR
GALLOWAY NJ
08205-3659
US

IV. Provider business mailing address

19 GREENWICH DR
GALLOWAY NJ
08205-3659
US

V. Phone/Fax

Practice location:
  • Phone: 732-977-4936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS01347500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: