Provider Demographics
NPI:1568839926
Name:KERLER, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KERLER
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 1:22 SAN PABLO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4122
Mailing Address - Country:US
Mailing Address - Phone:415-747-9669
Mailing Address - Fax:
Practice Address - Street 1:22 SAN PABLO AVE APT 2
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4122
Practice Address - Country:US
Practice Address - Phone:415-747-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAK1305171109101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC4415624Medicaid