Healthcare Provider Details

I. General information

NPI: 1972422012
Provider Name (Legal Business Name): ELISE KEELE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W INDEPENDENCE ST
JACKSON MO
63755-1882
US

IV. Provider business mailing address

661 W INDEPENDENCE ST
JACKSON MO
63755-1882
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-9753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberIA-0008409992
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: