Provider Demographics
NPI:1497798946
Name:KELLER, JESSICA B (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:KELLER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1912 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1708
Mailing Address - Country:US
Mailing Address - Phone:434-845-8765
Mailing Address - Fax:
Practice Address - Street 1:1912 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1708
Practice Address - Country:US
Practice Address - Phone:434-845-8765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004978757Medicaid
VA192596OtherANTHEM BC/BS
VA496612Medicare ID - Type Unspecified