MEDICARE: OPHELIA KELLY L.P.C.

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	104100000X	Social Worker	W0803	MS
2	101YP2500X	Professional Counselor	1820	MS

General Provider Information

NPI Number	:	1568706141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OPHELIA KELLY L.P.C.

Provider Business Mailing Address
First Line	:	105 MEADOWVIEW CIR
Second Line	:
City	:	CLINTON
State	:	MS
Zip	:	39056-5907
Country	:	US
Telephone Number	:	601-608-8680
Fax Number	:

Provider Business Practice Location Address
First Line	:	2941 TERRY RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-3073
Country	:	US
Telephone Number	:	601-373-0566
Fax Number	:	601-373-0566

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

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	08/22/2016

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Directions to “ OPHELIA KELLY L.P.C.” Practice Location

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