Provider Demographics
NPI:1316547763
Name:KELLER, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-4634
Mailing Address - Country:US
Mailing Address - Phone:954-410-7409
Mailing Address - Fax:
Practice Address - Street 1:3050 MEADOW LN
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-4634
Practice Address - Country:US
Practice Address - Phone:954-410-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5575225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist