Provider Demographics
NPI:1699222802
Name:KEELER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KEELER
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 1:333 W PIERCE RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-3116
Mailing Address - Country:US
Mailing Address - Phone:630-773-1985
Mailing Address - Fax:630-773-1988
Practice Address - Street 1:333 W PIERCE RD
Practice Address - Street 2:SUITE 175
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-3116
Practice Address - Country:US
Practice Address - Phone:630-773-1985
Practice Address - Fax:630-773-1988
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0106711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-141Medicaid