=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952000754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JKIV, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2023
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 PLAINS RD STE 1B
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06461-2573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-400-8607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 VINCELLETTE ST UNIT 64
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06606-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN KEANE IV
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 203-451-0195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------