MEDICARE: MS. KELLY JO LOCKWOOD LCSW

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	1041C0700X	Clinical Social Worker	6801079984	MI

General Provider Information

NPI Number	:	1558697003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY JO LOCKWOOD LCSW

Provider Business Mailing Address
First Line	:	3053 GILMORE LN
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-8683
Country	:	US
Telephone Number	:	616-916-7725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2874 PORT SHELDON ST
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-7898
Country	:	US
Telephone Number	:	616-916-7725
Fax Number	:

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

Provider Enumeration Date	:	10/19/2009
Last Update Date	:	11/24/2020

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