Provider Demographics
NPI:1417601279
Name:OVERLUND, KEYONNA JADE
Entity Type:Individual
Prefix:
First Name:KEYONNA
Middle Name:JADE
Last Name:OVERLUND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAYDEN
Other - Middle Name:BENJAMIN
Other - Last Name:GREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 101 STE 204
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9371
Mailing Address - Country:US
Mailing Address - Phone:503-325-5722
Mailing Address - Fax:
Practice Address - Street 1:486 12TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4122
Practice Address - Country:US
Practice Address - Phone:503-325-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator