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General NPI Number Information
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NPI Number | 1982968210
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Entity Type | Individual
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Provider Name | JACK LOGAN KEITH JR. PMHNP
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Gender | Male
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 6102 84TH AVENUE CT W
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98467-4042
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Country | US
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Telephone | 360-870-5411
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Fax | 888-414-8151
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Provider Business Mailing Address
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Address Line | 6102 84TH AVENUE CT W
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98467-4042
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Country | US
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Telephone | 360-870-5411
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Fax | 888-414-8151
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 202110580NP-PP
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP61193548
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License Number State | WA
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