Provider Demographics
NPI:1225683808
Name:KETTNER, JACOB (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KETTNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6815 ISAACS ORCHARD RD STE D
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6285
Mailing Address - Country:US
Mailing Address - Phone:479-856-6400
Mailing Address - Fax:
Practice Address - Street 1:3399 BLACK FOREST DR STE 3
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6541
Practice Address - Country:US
Practice Address - Phone:417-300-9965
Practice Address - Fax:417-494-4173
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARPT4666225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist