Provider Demographics
NPI:1043920929
Name:CARTER, KEITH JEROME (PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JEROME
Last Name:CARTER
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JORIE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2219
Mailing Address - Country:US
Mailing Address - Phone:630-974-6602
Mailing Address - Fax:630-487-2411
Practice Address - Street 1:14300 S RAVINIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2578
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:630-487-2411
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026498363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health