Provider Demographics
NPI:1326543877
Name:KEITH, JACQUELINE KELLY (MSN, RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KELLY
Last Name:KEITH
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:174 SADDLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-9174
Mailing Address - Country:US
Mailing Address - Phone:919-721-0118
Mailing Address - Fax:
Practice Address - Street 1:130 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4009
Practice Address - Country:US
Practice Address - Phone:919-774-6521
Practice Address - Fax:919-776-6179
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC141062364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult