Provider Demographics
NPI:1417266578
Name:JASON KELLER, PSY.D., PLLC
Entity type:Organization
Organization Name:JASON KELLER, PSY.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:502-322-4884
Mailing Address - Street 1:1512 CRUMS LN
Mailing Address - Street 2:SUITE 305
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-3861
Mailing Address - Country:US
Mailing Address - Phone:502-322-4884
Mailing Address - Fax:
Practice Address - Street 1:1512 CRUMS LN
Practice Address - Street 2:SUITE 305
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-3861
Practice Address - Country:US
Practice Address - Phone:502-322-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X, 103K00000X, 103TC2200X
KY1548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty