Basic Information
| Provider Information | |||||||||
| NPI: | 1902414188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 MURDOCK AVE | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128012407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098645176 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 WILLOWBROOK RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128045882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189267100 | ||||||||
| FaxNumber: | 5189267069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 109506 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.