Healthcare Provider Details

I. General information

NPI: 1144751710
Provider Name (Legal Business Name): JACLYN MICHELLE KELLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 12/19/2024
Certification Date: 12/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980 PREMIER DR STE 110
HIGH POINT NC
27265-8409
US

IV. Provider business mailing address

18 KNOLL BROOK CT
GREENSBORO NC
27407-6107
US

V. Phone/Fax

Practice location:
  • Phone: 336-396-9239
  • Fax: 336-900-1238
Mailing address:
  • Phone: 336-396-9239
  • Fax: 336-900-1238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC015008
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: