MEDICARE: MR. JAY KIMBALL KEELER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1062923501	UT

General Provider Information

NPI Number	:	1275503336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAY KIMBALL KEELER LCSW

Provider Business Mailing Address
First Line	:	4460 HIGHLAND DR
Second Line	:	SUITE #100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3543
Country	:	US
Telephone Number	:	801-273-1085
Fax Number	:	801-273-4097

Provider Business Practice Location Address
First Line	:	4460 HIGHLAND DR
Second Line	:	SUITE #100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3543
Country	:	US
Telephone Number	:	801-273-1085
Fax Number	:	801-273-4097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	07/09/2007

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