Provider Demographics
NPI:1275296758
Name:KELLER, JAYMIE LOREN (LMHC)
Entity Type:Individual
Prefix:
First Name:JAYMIE
Middle Name:LOREN
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 LAWNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-2657
Mailing Address - Country:US
Mailing Address - Phone:813-928-8479
Mailing Address - Fax:
Practice Address - Street 1:1206 LAWNSIDE AVE
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-2657
Practice Address - Country:US
Practice Address - Phone:813-928-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health