MEDICARE: MRS. JENNIFER KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1063533743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER KELLY

Provider Business Mailing Address
First Line	:	1212 N LASALLE ST APT 1505
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-8037
Country	:	US
Telephone Number	:	708-476-0142
Fax Number	:	312-664-7063

Provider Business Practice Location Address
First Line	:	1212 N LASALLE ST APT 1505
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-8037
Country	:	US
Telephone Number	:	708-476-0142
Fax Number	:	312-664-7063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	04/28/2009

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