1568047686 NPI number — JENNIFER L KELLER MSN, BSW, PMHNP-BC

Table of content: JENNIFER L KELLER MSN, BSW, PMHNP-BC (NPI 1568047686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568047686 NPI number — JENNIFER L KELLER MSN, BSW, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, BSW, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BELL
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568047686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 680
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSSIPEE
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03864-0680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-651-8835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 NH-28
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
OSSIPEE
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-651-8835
Provider Business Practice Location Address Fax Number:
603-316-6035
Provider Enumeration Date:
03/10/2021

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: 363LP0808X , with the licence number:  084560-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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