Provider Demographics
NPI:1295900744
Name:KEYES, JORDAN D (CST)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:D
Last Name:KEYES
Suffix:
Gender:M
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 1ST ST
Mailing Address - Street 2:STE 280
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6100
Mailing Address - Country:US
Mailing Address - Phone:208-345-6545
Mailing Address - Fax:208-345-1213
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:STE 280
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-345-6545
Practice Address - Fax:208-345-1213
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID89506246X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular