Jack Kelly, BCBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-20-45283 Issued in IL

Practice address

917 Sherwood Dr Ste 201
Lake Bluff, IL 60044-2235

Phone

(877) 486-4140

NPI assigned

Dec 12, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1576108800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1628726400000",
    "number": "1396383030",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "426 W BELMONT AVE APT 807",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606574721",
            "telephone_number": "773-386-4024"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "917 SHERWOOD DR STE 201",
            "city": "LAKE BLUFF",
            "state": "IL",
            "postal_code": "600442235",
            "telephone_number": "877-486-4140"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1975 McDowell Rd. #101",
            "address_purpose": "LOCATION",
            "city": "Naperville",
            "state": "IL",
            "postal_code": "60563",
            "country_code": "US",
            "telephone_number": "331-229-8839",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELLY",
        "first_name": "JACK",
        "credential": "BCBA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-12-12",
        "last_updated": "2021-08-12",
        "certification_date": "2021-08-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "106E00000X",
            "taxonomy_group": "",
            "desc": "Assistant Behavior Analyst",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "IL",
            "license": "1-20-45283",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Behavior Analyst in Lake Bluff, IL
• Providers in Lake Bluff, IL by specialty
• Behavior Analyst in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.