Provider Demographics
NPI:1912077264
Name:KEOUGH, JEAN
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:KEOUGH
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3253
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S DEVELOPMENTAL SERVICES AGENCY - DEPT OF PED
Practice Address - Street 2:IRONS BUILDING - OGLESBY DR.
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-737-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC48521225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC48521OtherBCBS NC