Provider Demographics
NPI:1982688180
Name:KETTNER, JUDITH TART (LPC MS LMFT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:TART
Last Name:KETTNER
Suffix:
Gender:F
Credentials:LPC MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VALENCIA DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7356
Mailing Address - Country:US
Mailing Address - Phone:910-346-9000
Mailing Address - Fax:910-355-0672
Practice Address - Street 1:200 VALENCIA DR
Practice Address - Street 2:SUITE 109
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7356
Practice Address - Country:US
Practice Address - Phone:910-346-9000
Practice Address - Fax:910-355-0672
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC LPC 3778101YP2500X
NCNC LMFT 516106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
131CHOtherBLUE CROSS BLUE SHIELD