Provider Demographics
NPI:1205340742
Name:KEEFE, JESSICA (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KEEFE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:349 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-3005
Practice Address - Country:US
Practice Address - Phone:401-942-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN01614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI05-0414696Medicaid