1043612468 NPI number — JESSICA L O'KEEFE PA-C

Table of content: JESSICA L O'KEEFE PA-C (NPI 1043612468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043612468 NPI number — JESSICA L O'KEEFE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'KEEFE
Provider First Name:
JESSICA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESTEFANO
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043612468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19847 CENTURY BLVD STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20874-7204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-912-2206
Provider Business Mailing Address Fax Number:
240-912-2381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19847 CENTURY BLVD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20874-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-912-2206
Provider Business Practice Location Address Fax Number:
240-912-2381
Provider Enumeration Date:
09/17/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C0005538 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)