Provider Demographics
NPI:1942741301
Name:KETTLEY, JOHN (MSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KETTLEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W NORTH TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9222
Mailing Address - Country:US
Mailing Address - Phone:734-358-7116
Mailing Address - Fax:
Practice Address - Street 1:1221 W NORTH TERRITORIAL RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9222
Practice Address - Country:US
Practice Address - Phone:734-358-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010102811041C0700X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health