Provider Demographics
NPI:1053023770
Name:KELLY, JONATHAN ROBERT (LMSW)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W 171ST ST APT 22A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1948
Mailing Address - Country:US
Mailing Address - Phone:631-816-4068
Mailing Address - Fax:
Practice Address - Street 1:5505 NESCONSET HWY STE 222
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2026
Practice Address - Country:US
Practice Address - Phone:631-892-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117202-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical