Basic Information
| Provider Information | |||||||||
| NPI: | 1912477647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | JENEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | MINNESOTA AVENUE | ||||||||
| Address2: | 3946 MINNESOTA AVENUE NE | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200196044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023988683 | ||||||||
| FaxNumber: | 2025488600 | ||||||||
| Practice Location | |||||||||
| Address1: | MINNESOTA AVENUE | ||||||||
| Address2: | 3946 MINNESOTA AVENUE NE | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200196044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023988683 | ||||||||
| FaxNumber: | 2025488600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701007939 | VA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | PRC14827 | DC | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.