1922611557 NPI number — JAMIE MARIE KEEVER RD, LD, CLC

Table of content: JAMIE MARIE KEEVER RD, LD, CLC (NPI 1922611557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922611557 NPI number — JAMIE MARIE KEEVER RD, LD, CLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEEVER
Provider First Name:
JAMIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISHER
Provider Other First Name:
JAMIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LD, CLC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922611557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5962 MCJESSY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43081-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5962 MCJESSY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43081-7130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-966-1363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2020

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: 133V00000X , with the licence number:  LD.7522 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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