Provider Demographics
NPI:1629376736
Name:KETCHENS, JERALD LOUIS (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:LOUIS
Last Name:KETCHENS
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4212
Mailing Address - Country:US
Mailing Address - Phone:318-322-3312
Mailing Address - Fax:312-322-3354
Practice Address - Street 1:716 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4212
Practice Address - Country:US
Practice Address - Phone:318-322-3312
Practice Address - Fax:312-322-3354
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist