Provider Demographics
NPI:1376502153
Name:KEADY, JENNIFER REBECCA (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:REBECCA
Last Name:KEADY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1551
Mailing Address - Country:US
Mailing Address - Phone:541-573-1575
Mailing Address - Fax:
Practice Address - Street 1:406 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1551
Practice Address - Country:US
Practice Address - Phone:541-573-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3103T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231403Medicaid
OR5509310001Medicare NSC