Provider Demographics
NPI:1447914932
Name:KELLER, JAYSON P
Entity type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:P
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1215
Mailing Address - Country:US
Mailing Address - Phone:304-453-3503
Mailing Address - Fax:
Practice Address - Street 1:1405 OAK ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1215
Practice Address - Country:US
Practice Address - Phone:304-453-3503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0012798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist