Healthcare Provider Details

I. General information

NPI: 1164048229
Provider Name (Legal Business Name): JACOB KEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 NORTHRIDGE DR
LEWISBURG WV
24901-0010
US

IV. Provider business mailing address

962 COFFMAN CEMETERY RD
LEWISBURG WV
24901-5629
US

V. Phone/Fax

Practice location:
  • Phone: 304-661-3825
  • Fax:
Mailing address:
  • Phone: 304-661-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number164W00000X
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: