Provider Demographics
NPI:1912671538
Name:BROTHERS, KEENAN JORDAN
Entity type:Individual
Prefix:
First Name:KEENAN
Middle Name:JORDAN
Last Name:BROTHERS
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 1:3126 W CARY ST # 116
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3504
Mailing Address - Country:US
Mailing Address - Phone:252-677-5100
Mailing Address - Fax:252-677-5110
Practice Address - Street 1:1431B WEEKSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8431
Practice Address - Country:US
Practice Address - Phone:252-677-5100
Practice Address - Fax:252-677-5110
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician