Provider Demographics
NPI:1275015901
Name:KEITH, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 S MCINTIRE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4225
Mailing Address - Country:US
Mailing Address - Phone:181-233-2876
Mailing Address - Fax:812-336-3425
Practice Address - Street 1:2907 S MCINTIRE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4225
Practice Address - Country:US
Practice Address - Phone:181-233-2876
Practice Address - Fax:812-336-3425
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002549A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002549AOtherSTATE LICENSE NUMBER