Provider Demographics
NPI:1053637611
Name:MCKELLER, JIMMY C JR (LPC-CR, LCDC III)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:C
Last Name:MCKELLER
Suffix:JR
Gender:M
Credentials:LPC-CR, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2161 BISHOPSGATE DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2161 BISHOPSGATE DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2005
Practice Address - Country:US
Practice Address - Phone:419-380-8537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC000258101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional