Provider Demographics
NPI:1093421687
Name:KEITH, JESSE LEE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:KEITH
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 1:3301 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-2418
Mailing Address - Country:US
Mailing Address - Phone:916-210-8773
Mailing Address - Fax:
Practice Address - Street 1:3301 37TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-2418
Practice Address - Country:US
Practice Address - Phone:916-210-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137043106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist