1144751710 NPI number — MRS. JACLYN MICHELLE KELLER LCSW

Table of content: MRS. JACLYN MICHELLE KELLER LCSW (NPI 1144751710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144751710 NPI number — MRS. JACLYN MICHELLE KELLER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
JACLYN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144751710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 KNOLL BROOK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-6107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-396-9239
Provider Business Mailing Address Fax Number:
336-900-1238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3980 PREMIER DR STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27265-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-396-9239
Provider Business Practice Location Address Fax Number:
336-900-1238
Provider Enumeration Date:
03/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C015008 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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