Provider Demographics
NPI:1376135137
Name:KEITH, JONATHAN W (MSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:KEITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 BERMUDA HILLS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6808
Mailing Address - Country:US
Mailing Address - Phone:803-651-1460
Mailing Address - Fax:
Practice Address - Street 1:1111 DOYLE ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4797
Practice Address - Country:US
Practice Address - Phone:803-395-8173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker