Provider Demographics
NPI:1144751710
Name:KELLER, JACLYN MICHELLE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MICHELLE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42267 W MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-8683
Mailing Address - Country:US
Mailing Address - Phone:520-255-5265
Mailing Address - Fax:
Practice Address - Street 1:21476 N JOHN WAYNE PKWY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8983
Practice Address - Country:US
Practice Address - Phone:520-316-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-15572104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker