Healthcare Provider Details

I. General information

NPI: 1932601374
Provider Name (Legal Business Name): JENNIFER ARDELL KELLER NP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ARDELL DE FAZIO

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 ANSLEY DR STE 700
DAHLONEGA GA
30533-1641
US

IV. Provider business mailing address

571 S ALLEN RD
FLAT ROCK NC
28731-9447
US

V. Phone/Fax

Practice location:
  • Phone: 706-701-5001
  • Fax: 706-701-5002
Mailing address:
  • Phone: 828-692-6178
  • Fax: 828-692-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN178949
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN178949
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number382103
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: