Provider Demographics
NPI:1538679220
Name:JEAN, KETHLY (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KETHLY
Middle Name:
Last Name:JEAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 FOSTER AVE APT 5J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1665
Mailing Address - Country:US
Mailing Address - Phone:917-723-3091
Mailing Address - Fax:
Practice Address - Street 1:1119 FOSTER AVE APT 5J
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1665
Practice Address - Country:US
Practice Address - Phone:917-723-3091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY685837-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse