Provider Demographics
NPI:1790863355
Name:JEANE, MARTIN KELLER (PHD, LPC-S, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:KELLER
Last Name:JEANE
Suffix:
Gender:M
Credentials:PHD, LPC-S, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 REGENCY PARKWAY
Mailing Address - Street 2:#601
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7306
Mailing Address - Country:US
Mailing Address - Phone:817-539-0499
Mailing Address - Fax:817-539-0498
Practice Address - Street 1:305 REGENCY PARKWAY
Practice Address - Street 2:#601
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7306
Practice Address - Country:US
Practice Address - Phone:817-539-0499
Practice Address - Fax:817-539-0498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08035101YP2500X
TX116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX052194000OtherMAGELLAN PROV ID
TX1017LCOtherBLUE CROSS BLUE SHIELD
TX025581201Medicaid
TX128615OtherMHN PROVIDER ID
TX10029868OtherAMERIGROUP PROV. ID
TX143906OtherVALUEOPTIONS ID