Provider Demographics
NPI:1093185100
Name:KEATING, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KEATING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1082 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-8718
Mailing Address - Country:US
Mailing Address - Phone:614-787-3247
Mailing Address - Fax:
Practice Address - Street 1:1082 WHITETAIL DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-8718
Practice Address - Country:US
Practice Address - Phone:614-787-3247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121035101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN351928552Medicaid