Provider Demographics
NPI:1336504174
Name:KEEFE, JENNY CARTER
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:CARTER
Last Name:KEEFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 W DR MLK BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6055
Mailing Address - Country:US
Mailing Address - Phone:813-877-6748
Mailing Address - Fax:813-875-0359
Practice Address - Street 1:2727 W DR MLK BLVD STE 320
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6055
Practice Address - Country:US
Practice Address - Phone:813-877-6748
Practice Address - Fax:813-875-0359
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109352363AS0400X, 363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016687400Medicaid