Provider Demographics
NPI:1083976146
Name:KEANE, JENNIFER (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEANE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4938 N SHAW LOOP RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7005
Mailing Address - Country:US
Mailing Address - Phone:208-699-5536
Mailing Address - Fax:
Practice Address - Street 1:1717 LINCOLN WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2556
Practice Address - Country:US
Practice Address - Phone:208-699-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional