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General NPI Number Information
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NPI Number | 1396383030
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Entity Type | Individual
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Provider Name | JACK KELLY BCBA
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Gender | Male
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Dates
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Enumeration Date | 12/12/2019
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 917 SHERWOOD DR STE 201
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City | LAKE BLUFF
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State | IL
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Zip | 60044-2235
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Country | US
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Telephone | 877-486-4140
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Fax |
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Provider Business Mailing Address
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Address Line | 426 W BELMONT AVE APT 807
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City | CHICAGO
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State | IL
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Zip | 60657-4721
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Country | US
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Telephone | 773-386-4024
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-20-45283
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License Number State | IL
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