Provider Demographics
NPI:1629102280
Name:JENKS KETTMANN, JULIE (MED)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:JENKS KETTMANN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 WOOLRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-3026
Mailing Address - Country:US
Mailing Address - Phone:309-255-5281
Mailing Address - Fax:
Practice Address - Street 1:2102 E 38TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1135
Practice Address - Country:US
Practice Address - Phone:563-359-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00996101YP2500X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional