Healthcare Provider Details

I. General information

NPI: 1538092457
Provider Name (Legal Business Name): JEANETTE MARIE KEITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PERKINS LN
JACKSBORO TN
37757-2833
US

IV. Provider business mailing address

114 PERKINS LN
JACKSBORO TN
37757-2833
US

V. Phone/Fax

Practice location:
  • Phone: 802-528-9807
  • Fax:
Mailing address:
  • Phone: 802-528-9807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: