Provider Demographics
NPI:1629340856
Name:KELLER, JACOB R (LPCC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:KELLER
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-1624
Mailing Address - Country:US
Mailing Address - Phone:937-475-9124
Mailing Address - Fax:
Practice Address - Street 1:411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-1624
Practice Address - Country:US
Practice Address - Phone:937-475-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1000620101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional