Basic Information
Provider Information | |||||||||
NPI: | 1104324573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KEENE | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LATHUM | ||||||||
OtherFirstName: | JENNY | ||||||||
OtherMiddleName: | LYNNE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 402 S SILVER SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637037536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733341100 | ||||||||
FaxNumber: | 5736514345 | ||||||||
Practice Location | |||||||||
Address1: | 103 EL NATHAN DRIVE | ||||||||
Address2: |   | ||||||||
City: | MARBLE HILL | ||||||||
State: | MO | ||||||||
PostalCode: | 637648342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5732381027 | ||||||||
FaxNumber: | 5732381171 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2018 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2015037534 | MO | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 218042356 | MO | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 490050878 | 05 | MO |   | MEDICAID |