Provider Demographics
NPI:1295105682
Name:KELLER, JENNIFER I (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KELLER
Suffix:I
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 LAKE COOK RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4920
Mailing Address - Country:US
Mailing Address - Phone:847-600-4124
Mailing Address - Fax:
Practice Address - Street 1:770 LAKE COOK RD
Practice Address - Street 2:SUITE 320
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4920
Practice Address - Country:US
Practice Address - Phone:847-600-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical