Provider Demographics
NPI:1629169099
Name:KEENAN, JEANNETTE D (MA)
Entity Type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:D
Last Name:KEENAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 CONCORD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-1513
Mailing Address - Country:US
Mailing Address - Phone:802-748-5364
Mailing Address - Fax:802-748-7289
Practice Address - Street 1:231 CONCORD AVE STE 1
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1513
Practice Address - Country:US
Practice Address - Phone:802-748-5364
Practice Address - Fax:802-748-7289
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT393103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002184Medicaid