Provider Demographics
NPI:1447659842
Name:KELLER, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:2 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1156
Mailing Address - Country:US
Mailing Address - Phone:618-697-4523
Mailing Address - Fax:
Practice Address - Street 1:924 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2637
Practice Address - Country:US
Practice Address - Phone:618-252-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006702225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant