Provider Demographics
NPI:1922575257
Name:KELLY, JAMIE LEE (SUDP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:KELLY
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 N LACEY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-2443
Mailing Address - Country:US
Mailing Address - Phone:509-325-6800
Mailing Address - Fax:509-321-0706
Practice Address - Street 1:1321 N ASH ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2803
Practice Address - Country:US
Practice Address - Phone:509-327-3120
Practice Address - Fax:509-327-3228
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60429390101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)