Provider Demographics
NPI:1336300482
Name:KEENUM, JACQUELINE THERESE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:THERESE
Last Name:KEENUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 HARRISON PIKE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-1422
Mailing Address - Country:US
Mailing Address - Phone:423-227-9474
Mailing Address - Fax:
Practice Address - Street 1:2554 HARRISON PIKE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-1422
Practice Address - Country:US
Practice Address - Phone:423-227-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMT0000006538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMT 0000006538OtherTENNESSEE MASSAGE THERAPY BOARD