Healthcare Provider Details

I. General information

NPI: 1619569357
Provider Name (Legal Business Name): JACQUELINE R KEUCHLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROAD RD STE 4K
SYRACUSE NY
13215-2265
US

IV. Provider business mailing address

4900 BROAD RD STE 4K
SYRACUSE NY
13215-2265
US

V. Phone/Fax

Practice location:
  • Phone: 617-913-5922
  • Fax:
Mailing address:
  • Phone: 315-492-5784
  • Fax: 315-492-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberP108016
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1619569357
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: