MEDICARE: MR. MARTIN KELLER JEANE PH.D., LPC-S, LMFT

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	101YP2500X	Professional Counselor	08035	TX
2	106H00000X	Marriage & Family Therapist	116	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	052194000	OTHER	TX	MAGELLAN PROV ID
2	1017LC	OTHER	TX	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	128615	OTHER	TX	MHN PROVIDER ID
5	10029868	OTHER	TX	AMERIGROUP PROV. ID
6	143906	OTHER	TX	VALUEOPTIONS ID

General Provider Information

NPI Number	:	1790863355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN KELLER JEANE PH.D., LPC-S, LMFT

Provider Business Mailing Address
First Line	:	305 REGENCY PARKWAY
Second Line	:	#601
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7306
Country	:	US
Telephone Number	:	817-539-0499
Fax Number	:	817-539-0498

Provider Business Practice Location Address
First Line	:	305 REGENCY PARKWAY
Second Line	:	#601
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7306
Country	:	US
Telephone Number	:	817-539-0499
Fax Number	:	817-539-0498

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/10/2015

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Directions to “ MR. MARTIN KELLER JEANE PH.D., LPC-S, LMFT” Practice Location

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