Provider Demographics
NPI:1548673395
Name:JARVIS, KEITH (MASTERS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:JARVIS
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 EAST ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-4421
Mailing Address - Country:US
Mailing Address - Phone:401-724-8400
Mailing Address - Fax:401-722-5280
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-4421
Practice Address - Country:US
Practice Address - Phone:401-724-8400
Practice Address - Fax:401-722-5280
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW027221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid