Healthcare Provider Details

I. General information

NPI: 1902420995
Provider Name (Legal Business Name): JESSICA MARIE KEERAN MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13600 ROUTE C
RUSSELLVILLE MO
65074-2033
US

IV. Provider business mailing address

PO BOX 1128
JEFFERSON CITY MO
65102-1128
US

V. Phone/Fax

Practice location:
  • Phone: 573-782-4814
  • Fax:
Mailing address:
  • Phone: 573-632-5614
  • Fax: 573-632-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14074389
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: