Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PSY004154 | GA |
Y | 103T00000X | Psychologist | PSY004154 | GA |
NPI | 1003308941 |
---|---|
Provider Name | Jessica Maples Keller |
First Address | Decatur, GA 30033-5519 |
Second Address | Atlanta, GA 30329-2206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2018 |
Last Update Date | 06/06/2018 |