Provider Demographics
NPI:1922033828
Name:KELLER, JENNIFER NICOLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28199
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0199
Mailing Address - Country:US
Mailing Address - Phone:858-675-3100
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:STE D4
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-674-1600
Practice Address - Fax:858-674-1606
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG677YMedicare PIN
CAQ48472Medicare UPIN