Provider Demographics
NPI:1467873034
Name:KEETON, JODY (NP-C)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:
Last Name:KEETON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E SAN FERNANDO ST
Mailing Address - Street 2:APT. 516
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-7423
Mailing Address - Country:US
Mailing Address - Phone:859-619-1202
Mailing Address - Fax:
Practice Address - Street 1:10455 S DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3011
Practice Address - Country:US
Practice Address - Phone:859-619-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily