Provider Demographics
NPI:1164048229
Name:KEATON, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KEATON
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 1:962 COFFMAN CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-5629
Mailing Address - Country:US
Mailing Address - Phone:304-661-3825
Mailing Address - Fax:
Practice Address - Street 1:348 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-0010
Practice Address - Country:US
Practice Address - Phone:304-661-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 373H00000X
WV164W00000X163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist