Provider Demographics
NPI:1407939473
Name:KELLER, JASON (PSY D)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 STONE CREEK PKWY STE 7
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5366
Mailing Address - Country:US
Mailing Address - Phone:502-423-0332
Mailing Address - Fax:502-423-0337
Practice Address - Street 1:800 STONE CREEK PKWY STE 7
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5366
Practice Address - Country:US
Practice Address - Phone:502-423-0332
Practice Address - Fax:502-423-0337
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
KY1548103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000540906OtherANTHEM
KY30605018Medicaid
KY0763553Medicare PIN
KY00206011Medicare PIN
KY000000540906OtherANTHEM
KY30605018Medicaid
KY00201013Medicare PIN
KY0690957Medicare PIN
KY0762353Medicare PIN
KY0974726Medicare PIN
KY00200013Medicare PIN
KY00199013Medicare PIN
KY0762257Medicare PIN