Provider Demographics
NPI:1144522574
Name:KELLY, JONATHAN RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RICHARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:51 NORTH BRAINARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-0575
Mailing Address - Country:US
Mailing Address - Phone:708-482-0090
Mailing Address - Fax:708-579-3954
Practice Address - Street 1:600 SOUTH PAULINA STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-2832
Practice Address - Fax:708-579-3954
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360590142084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry