Provider Demographics
NPI:1083776173
Name:KETOLA, JARLINE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JARLINE
Middle Name:ANN
Last Name:KETOLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 MACAFEE RD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4331
Mailing Address - Country:US
Mailing Address - Phone:310-541-6145
Mailing Address - Fax:
Practice Address - Street 1:24586 HAWTHORNE BLVD
Practice Address - Street 2:#103
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6857
Practice Address - Country:US
Practice Address - Phone:310-541-6145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14457103T00000X
CA215972163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14457BMedicare PIN