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General NPI Number Information
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NPI Number | 1306649884
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Entity Type | Organization
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Legal Business Name | KEYSTONE TIDES, PLLC
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Dates
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Enumeration Date | 03/31/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 115 E RAILROAD AVE STE 203
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City | PORT ANGELES
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State | WA
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Zip | 98362-2925
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Country | US
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Telephone | 425-400-8602
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Fax | 425-433-9177
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Provider Business Mailing Address
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Address Line | 132 DEER PARK RD # 21
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City | PORT ANGELES
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State | WA
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Zip | 98362-7185
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Country | US
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Telephone | 425-400-8602
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Fax | 425-433-9177
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA JOHNSON
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Credential | ARNP
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Telephone | 303-775-0065
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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