MEDICARE: MS. JENNESS MARIE KELLER MPH, RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	802441	CA

General Provider Information

NPI Number	:	1407889645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNESS MARIE KELLER MPH, RD

Provider Business Mailing Address
First Line	:	2670 BARDY RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-8540
Country	:	US
Telephone Number	:	707-545-3078
Fax Number	:

Provider Business Practice Location Address
First Line	:	3315 CHANATE RD
Second Line	:	SUTIE E
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-1736
Country	:	US
Telephone Number	:	707-570-3855
Fax Number	:	707-570-3850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/08/2007

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