Basic Information
| Provider Information | |||||||||
| NPI: | 1508245051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ELISABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLSTER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ELISABETHER | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 S RIVER RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037823039 | ||||||||
| FaxNumber: | 6037823667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3979 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.