Provider Demographics
NPI:1306649884
Name:KEYSTONE TIDES, PLLC
Entity type:Organization
Organization Name:KEYSTONE TIDES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:303-775-0065
Mailing Address - Street 1:132 DEER PARK RD # 21
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7185
Mailing Address - Country:US
Mailing Address - Phone:425-400-8602
Mailing Address - Fax:425-433-9177
Practice Address - Street 1:115 E RAILROAD AVE STE 203
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-2925
Practice Address - Country:US
Practice Address - Phone:425-400-8602
Practice Address - Fax:425-433-9177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health