Healthcare Provider Details

I. General information

NPI: 1356754931
Provider Name (Legal Business Name): JACK KELLER PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 TURNPIKE ST
CANTON MA
02021-2700
US

IV. Provider business mailing address

340 TURNPIKE ST
CANTON MA
02021-2700
US

V. Phone/Fax

Practice location:
  • Phone: 781-619-1500
  • Fax: 781-619-1509
Mailing address:
  • Phone: 781-619-1500
  • Fax: 781-619-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN10017560
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: