Provider Demographics
NPI:1548848401
Name:KEITH, JONATHAN MICHAEL NATHANIEL (LCSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL NATHANIEL
Last Name:KEITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-6131
Mailing Address - Country:US
Mailing Address - Phone:502-373-6632
Mailing Address - Fax:
Practice Address - Street 1:4010 DUPONT CIR STE 227
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4812
Practice Address - Country:US
Practice Address - Phone:502-373-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2555841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100733610Medicaid