Healthcare Provider Details

I. General information

NPI: 1699222802
Provider Name (Legal Business Name): JASON KEELER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W PIERCE RD SUITE 175
ITASCA IL
60143-3116
US

IV. Provider business mailing address

333 W PIERCE RD SUITE 175
ITASCA IL
60143-3116
US

V. Phone/Fax

Practice location:
  • Phone: 630-773-1985
  • Fax: 630-773-1988
Mailing address:
  • Phone: 630-773-1985
  • Fax: 630-773-1988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.010671
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: