Provider Demographics
NPI:1699165381
Name:KEAVENY, JESSICA
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:KEAVENY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 POWERS ST APT 12
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-4999
Mailing Address - Country:US
Mailing Address - Phone:603-365-5784
Mailing Address - Fax:
Practice Address - Street 1:220 S RIVER RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6819
Practice Address - Country:US
Practice Address - Phone:603-263-0062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPT4263183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician