Provider Demographics
NPI:1376826792
Name:KEITH, JASON B (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:B
Last Name:KEITH
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4838 TOWER RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-5853
Mailing Address - Country:US
Mailing Address - Phone:434-770-2704
Mailing Address - Fax:
Practice Address - Street 1:4838 TOWER RD
Practice Address - Street 2:UNIT D
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-5853
Practice Address - Country:US
Practice Address - Phone:434-770-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2014-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0075601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009073Medicaid
NC175A7OtherBLUE CROSS BLUE SHIELD
NC9836882OtherAETNA
NC6009073Medicaid