Provider Demographics
NPI:1639652977
Name:KEEFE, JESSICA (EDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KEEFE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 CARRIAGE HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-263-2700
Mailing Address - Fax:757-493-5437
Practice Address - Street 1:642 CARRIAGE HILL ROAD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452
Practice Address - Country:US
Practice Address - Phone:757-263-2700
Practice Address - Fax:757-493-5437
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000292103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000292OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS