Provider Demographics
NPI:1386318947
Name:KELLER, JORDAN R (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:R
Last Name:KELLER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 W CORNELIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3304
Mailing Address - Country:US
Mailing Address - Phone:773-895-7999
Mailing Address - Fax:
Practice Address - Street 1:5208 W CORNELIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3304
Practice Address - Country:US
Practice Address - Phone:773-895-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily