Provider Demographics
NPI:1477275071
Name:KETCHAM, JAYDEN
Entity Type:Individual
Prefix:
First Name:JAYDEN
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 FOREST ST STE 467
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2747
Mailing Address - Country:US
Mailing Address - Phone:213-864-1870
Mailing Address - Fax:
Practice Address - Street 1:16587 ENTERPRISE DR STE E
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-7902
Practice Address - Country:US
Practice Address - Phone:213-864-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician