Provider Demographics
NPI:1245094531
Name:KEITT, JONATHAN LATRELL
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LATRELL
Last Name:KEITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12109 PRAILS MILL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1586
Mailing Address - Country:US
Mailing Address - Phone:704-451-3878
Mailing Address - Fax:
Practice Address - Street 1:2020 REMOUNT RD STE E112
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7476
Practice Address - Country:US
Practice Address - Phone:704-451-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCM2024-11283-01175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist