Provider Demographics
NPI:1992408157
Name:JERRY KEITH COUNSELING LLC
Entity type:Organization
Organization Name:JERRY KEITH COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-399-2729
Mailing Address - Street 1:14448 SE BRIDGETON ST
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6270
Mailing Address - Country:US
Mailing Address - Phone:541-399-2729
Mailing Address - Fax:
Practice Address - Street 1:14448 SE BRIDGETON ST
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6270
Practice Address - Country:US
Practice Address - Phone:541-399-2729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty