Jack Logan Keith Jr., PMHNP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

AP61193548 Issued in WA

Practice address

6102 84TH Avenue CT W
University Place, WA 98467-4042

Phone

(360) 870-5411

Fax

(888) 414-8151

NPI assigned

Jul 2, 2012

Reactivated

Feb 13, 2020

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in OR, WA2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 2

Specialty

Nurse Practitioner

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Mindful Therapy Group PCGroup PAC ID 4981872561, 654 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mindful Mental Health, PLLC

  • Psychiatric/Mental Health Nurse Practitioner
  • University Place, WA
  • NPI 1932089281
  Medicare reassignment NPD Authorized official
• Mindful Therapy Group PC

  • Clinical Social Worker
  • Mountlake Terrace, WA
  • NPI 1316238678

  Mental Health, OR

  Medicare reassignment Care Compare group NPD
• Building Mental Health, LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Portland, OR
  • NPI 1821951203
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1341187200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1764720000000",
    "number": "1982968210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6102 84TH AVENUE CT W",
            "city": "UNIVERSITY PLACE",
            "state": "WA",
            "postal_code": "984674042",
            "telephone_number": "360-870-5411",
            "fax_number": "888-414-8151"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6102 84TH AVENUE CT W",
            "city": "UNIVERSITY PLACE",
            "state": "WA",
            "postal_code": "984674042",
            "telephone_number": "360-870-5411",
            "fax_number": "888-414-8151"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KEITH",
        "first_name": "JACK",
        "middle_name": "LOGAN",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "PMHNP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2012-07-02",
        "last_updated": "2025-12-03",
        "certification_date": "2025-12-03",
        "deactivation_date": "2020-01-15",
        "reactivation_date": "2020-02-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "OR",
            "license": "202110580NP-PP",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "WA",
            "license": "AP61193548",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eugenia Kang
• Kristin Josephine Kankelborg, PT
• Ray Jason Katzenbach, PH.D.
• Navreet Kaur, NP
• Ravneet Kaur, ARNP
• Kaitlyn Elizabeth Kelley, MA
• Virginia Kelly, M.A., CCC-SLP
• Claire Kilbourne
• Thomas Millar Killen, PHARMD
• Kim Aun DDS PS

• Psychiatric/Mental Health Nurse Practitioner in University Place, WA
• Providers in University Place, WA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.