Healthcare Provider Details

I. General information

NPI: 1821065236
Provider Name (Legal Business Name): JODI MCKEOWN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

3620 19TH ST APT 1
SAN FRANCISCO CA
94110-6712
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-8303
  • Fax:
Mailing address:
  • Phone: 808-561-1856
  • Fax: 415-206-4562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD-154
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number14883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: