Provider Demographics
NPI:1275561243
Name:KELLER, JAMES (JIM) L (PHD, PT)
Entity Type:Individual
Prefix:DR
First Name:JAMES (JIM)
Middle Name:L
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 S CARAWAY RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7307
Mailing Address - Country:US
Mailing Address - Phone:870-935-1414
Mailing Address - Fax:870-935-1425
Practice Address - Street 1:2929 S CARAWAY RD
Practice Address - Street 2:SUITE 15
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7307
Practice Address - Country:US
Practice Address - Phone:870-935-1414
Practice Address - Fax:870-935-1425
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5614225100000X
TN104225100000X
ARPT176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11424712OtherCAQH
AR149795742Medicaid
AR71076580230OtherQUALCHOICE
AR121901721Medicaid