Provider Demographics
NPI:1407236417
Name:KEENAN, JOLIE GUEVARA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOLIE
Middle Name:GUEVARA
Last Name:KEENAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 S I ST STE 405
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5094
Mailing Address - Country:US
Mailing Address - Phone:253-274-4545
Mailing Address - Fax:253-274-4599
Practice Address - Street 1:1624 S I ST STE 405
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5094
Practice Address - Country:US
Practice Address - Phone:253-274-4545
Practice Address - Fax:253-274-4599
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61018591207R00000X
WAMD61018591207RI0200X
IL036.145507208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2163044Medicaid