Provider Demographics
NPI:1629128137
Name:KEISEL, JOHNATHAN JACOB
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:JACOB
Last Name:KEISEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WHEELING ST # A1-116E
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-7211
Mailing Address - Country:US
Mailing Address - Phone:720-648-4766
Mailing Address - Fax:
Practice Address - Street 1:1700 NORTH WHEELING ST # A1-116E
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7211
Practice Address - Country:US
Practice Address - Phone:720-648-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2024-02-26
Deactivation Date:2019-08-21
Deactivation Code:
Reactivation Date:2024-02-21
Provider Licenses
StateLicense IDTaxonomies
COCSW.099272881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical