Provider Demographics
NPI:1851126205
Name:KEATLEY, JAYTHAN BRAD
Entity type:Individual
Prefix:
First Name:JAYTHAN
Middle Name:BRAD
Last Name:KEATLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3252
Mailing Address - Country:US
Mailing Address - Phone:330-220-2001
Mailing Address - Fax:330-220-2232
Practice Address - Street 1:1812 PEARL RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3252
Practice Address - Country:US
Practice Address - Phone:330-220-2001
Practice Address - Fax:330-220-2232
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.009182225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty