Provider Demographics
NPI:1609087402
Name:KETTERMAN, JAMIE L (RN, BSN, CDE)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:KETTERMAN
Suffix:
Gender:F
Credentials:RN, BSN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-8171
Mailing Address - Fax:660-890-8422
Practice Address - Street 1:1602 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-885-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000162289163WD0400X
MO2014022528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO357499904Medicaid
MO357499904Medicaid