Provider Demographics
NPI:1952168775
Name:KELLER, JILLIAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DUTCH LN
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1729
Mailing Address - Country:US
Mailing Address - Phone:716-319-7971
Mailing Address - Fax:
Practice Address - Street 1:400 BELCHASE DR STE 406
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9760
Practice Address - Country:US
Practice Address - Phone:732-851-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01237600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist