Provider Demographics
NPI:1336570886
Name:CLARK-KEELER, JESSICA (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CLARK-KEELER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 EDMUNDS RD
Mailing Address - Street 2:
Mailing Address - City:DANBY
Mailing Address - State:VT
Mailing Address - Zip Code:05739-9308
Mailing Address - Country:US
Mailing Address - Phone:802-293-5345
Mailing Address - Fax:
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4560
Practice Address - Country:US
Practice Address - Phone:802-775-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8900975181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0890097518OtherLICENSE