Provider Demographics
NPI:1417439381
Name:KEISER, JACQUELINE JOYCE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JOYCE
Last Name:KEISER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JACKIE
Other - Middle Name:JOYCE
Other - Last Name:KEISER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:69730 COUNTY ROAD 7
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-9321
Mailing Address - Country:US
Mailing Address - Phone:574-910-0390
Mailing Address - Fax:
Practice Address - Street 1:69730 COUNTY RD 7
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550
Practice Address - Country:US
Practice Address - Phone:574-773-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1329749222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist