Provider Demographics
NPI:1154466464
Name:KELLER, JESSICA ERIN (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ERIN
Last Name:KELLER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6508 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4022
Mailing Address - Country:US
Mailing Address - Phone:813-963-6923
Mailing Address - Fax:813-264-0768
Practice Address - Street 1:12220 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9201
Practice Address - Country:US
Practice Address - Phone:813-631-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8873235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891236000Medicaid