Provider Demographics
NPI:1275503336
Name:KEELER, JAY KIMBALL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:KIMBALL
Last Name:KEELER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JAY
Other - Middle Name:KIM
Other - Last Name:KEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4460 HIGHLAND DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3543
Mailing Address - Country:US
Mailing Address - Phone:801-273-1085
Mailing Address - Fax:801-273-4097
Practice Address - Street 1:4460 HIGHLAND DR
Practice Address - Street 2:SUITE #100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-273-1085
Practice Address - Fax:801-273-4097
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10629235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR79735Medicare UPIN