Provider Demographics
NPI:1669778502
Name:KELLER, JAMIE JO (LPN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:JO
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 STATE HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-9620
Mailing Address - Country:US
Mailing Address - Phone:920-559-7570
Mailing Address - Fax:
Practice Address - Street 1:4303 STATE HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-9620
Practice Address - Country:US
Practice Address - Phone:920-559-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134939164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse