Provider Demographics
NPI:1548825078
Name:KELLY, JEREMY MACLAREN (PHD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MACLAREN
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CRITTENDEN BLVD BOX PSYCH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-6900
Mailing Address - Fax:
Practice Address - Street 1:179 SULLYS TRL STE 200
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-4500
Practice Address - Country:US
Practice Address - Phone:585-276-6900
Practice Address - Fax:585-273-1066
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24880103TC0700X
NY024880-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical