Provider Demographics
NPI:1285772897
Name:KELLER, JAI BEA (LMHC)
Entity type:Individual
Prefix:
First Name:JAI
Middle Name:BEA
Last Name:KELLER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3522
Mailing Address - Country:US
Mailing Address - Phone:781-488-3503
Mailing Address - Fax:781-483-2221
Practice Address - Street 1:86 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3522
Practice Address - Country:US
Practice Address - Phone:781-488-3503
Practice Address - Fax:781-483-2221
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA#1354101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA#1354OtherL.M.H.C.