Provider Demographics
NPI:1982968210
Name:KEITH, JACK LOGAN JR (PMHNP)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:LOGAN
Last Name:KEITH
Suffix:JR
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6102 84TH AVENUE CT W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-4042
Mailing Address - Country:US
Mailing Address - Phone:360-870-5411
Mailing Address - Fax:888-414-8151
Practice Address - Street 1:6102 84TH AVENUE CT W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-4042
Practice Address - Country:US
Practice Address - Phone:360-870-5411
Practice Address - Fax:888-414-8151
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2025-12-03
Deactivation Date:2020-01-15
Deactivation Code:
Reactivation Date:2020-02-13
Provider Licenses
StateLicense IDTaxonomies
OR202110580NP-PP363LP0808X, 363LP0808X
WAAP61193548363LP0808X
WAN60493722163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse