Provider Demographics
NPI:1548302391
Name:KELLEY, JANE ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:ELLEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 HAYNES ST 235
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6702
Mailing Address - Country:US
Mailing Address - Phone:248-203-0191
Mailing Address - Fax:248-932-2949
Practice Address - Street 1:999 HAYNES ST 235
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6702
Practice Address - Country:US
Practice Address - Phone:248-203-0191
Practice Address - Fax:248-932-2949
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-F3-3238-0OtherBCBS
MION37490Medicare ID - Type Unspecified