Provider Demographics
NPI:1346011103
Name:KELLER, JODI MARIE
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:MARIE
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 1:750 E CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD BAY
Mailing Address - State:AR
Mailing Address - Zip Code:72088-3641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E CLIFF DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD BAY
Practice Address - State:AR
Practice Address - Zip Code:72088-3641
Practice Address - Country:US
Practice Address - Phone:501-238-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health