Provider Demographics
NPI:1144290784
Name:KELLER, JENNIFER ANNE (DPM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KELLER
Other - Last Name:FEENY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:60 SUMMERFIELD CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4579
Mailing Address - Country:US
Mailing Address - Phone:540-904-1458
Mailing Address - Fax:855-495-0994
Practice Address - Street 1:60 SUMMERFIELD CT
Practice Address - Street 2:SUITE 102
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4579
Practice Address - Country:US
Practice Address - Phone:540-904-1458
Practice Address - Fax:855-495-0994
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300725213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009304291Medicaid
VA480032174OtherRAILROAD MEDICARE
VA009304291Medicaid
480000709Medicare PIN