Healthcare Provider Details

I. General information

NPI: 1205267705
Provider Name (Legal Business Name): JACQUELINE KELLER MS, RD, CSP, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3133
  • Fax:
Mailing address:
  • Phone: 619-543-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: