Provider Demographics
NPI:1700021466
Name:KETCHUM, JENNIFER SUSANNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SUSANNE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:SUSANNE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:2600 EATON RAPIDS RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-887-7599
Mailing Address - Fax:
Practice Address - Street 1:2600 EATON RAPIDS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-887-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
MI7501004034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist