Provider Demographics
NPI:1558999664
Name:KEEGAN, JACK EZRA
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EZRA
Last Name:KEEGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:503-294-4321
Practice Address - Street 1:33 NW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3580
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200740083RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse