Provider Demographics
NPI:1508482290
Name:KEITH, JACIE MICHELLE (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:MICHELLE
Last Name:KEITH
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:JACIE
Other - Middle Name:MICHELLE
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9261
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-9261
Mailing Address - Country:US
Mailing Address - Phone:940-764-7230
Mailing Address - Fax:940-764-7255
Practice Address - Street 1:1301 3RD ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-2245
Practice Address - Country:US
Practice Address - Phone:940-764-8725
Practice Address - Fax:940-764-8719
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012258363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily