Provider Demographics
NPI:1003684119
Name:KETTLER, JACQUELINE GRACE (OTR/L)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:GRACE
Last Name:KETTLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:GRACE
Other - Last Name:ENGELBRECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2121 GOLDEN LAKE LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5899
Mailing Address - Country:US
Mailing Address - Phone:417-385-7650
Mailing Address - Fax:
Practice Address - Street 1:150 VILLAGE CROSSING CT
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-8697
Practice Address - Country:US
Practice Address - Phone:502-694-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23228225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist