Provider Demographics
NPI:1518248442
Name:KEENAN, JESSICA ELAINE (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:KEENAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 MURRAY DR
Mailing Address - Street 2:COMMUNITY MEDICAL CENTERS
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3339
Mailing Address - Country:US
Mailing Address - Phone:209-373-2816
Mailing Address - Fax:
Practice Address - Street 1:7210 MURRAY DR
Practice Address - Street 2:COMMUNITY MEDICAL CENTERS
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3339
Practice Address - Country:US
Practice Address - Phone:209-373-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A14197208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program