Provider Demographics
NPI:1184121444
Name:KELLER, JACQUELYNNE MARIE
Entity type:Individual
Prefix:
First Name:JACQUELYNNE
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S RYAN DR APT 7203
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-4270
Mailing Address - Country:US
Mailing Address - Phone:469-337-5097
Mailing Address - Fax:
Practice Address - Street 1:200 S RYAN DR APT 7203
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4270
Practice Address - Country:US
Practice Address - Phone:469-337-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty