Healthcare Provider Details

I. General information

NPI: 1386318947
Provider Name (Legal Business Name): JORDAN R KELLER FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 CHICAGO AVE
OAK PARK IL
60302-2402
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 773-253-3933
  • Fax: 773-437-6780
Mailing address:
  • Phone: 773-253-3933
  • Fax: 773-437-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.023699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: