Provider Demographics
NPI:1992707053
Name:KELLER, JASON TODD (DC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TODD
Last Name:KELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E REELFOOT AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5871
Mailing Address - Country:US
Mailing Address - Phone:731-885-7700
Mailing Address - Fax:731-885-7704
Practice Address - Street 1:1003 E REELFOOT AVE
Practice Address - Street 2:STE 1
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:731-885-7700
Practice Address - Fax:731-885-7704
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3067070OtherCIGNA HEALTHCARE
TN3120562OtherBCBS OF TN
TN6198630001Medicare NSC
TN3970368Medicare ID - Type Unspecified