Healthcare Provider Details

I. General information

NPI: 1437530953
Provider Name (Legal Business Name): JENNIFER KELLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

7470A DELMAR BLVD
SAINT LOUIS MO
63130-4034
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8317
  • Fax:
Mailing address:
  • Phone: 847-275-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2015017624
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2022027081
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: