Provider Demographics
NPI:1922559954
Name:KAETZEL, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KAETZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 EASY CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7340
Mailing Address - Country:US
Mailing Address - Phone:616-405-5892
Mailing Address - Fax:
Practice Address - Street 1:1646 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2204
Practice Address - Country:US
Practice Address - Phone:616-405-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN97068282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer