Provider Demographics
NPI:1255733861
Name:KETTMANN, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KETTMANN
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 1:1421 GUERNEVILLE RD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7220
Mailing Address - Country:US
Mailing Address - Phone:707-752-1422
Mailing Address - Fax:
Practice Address - Street 1:1421 GUERNEVILLE RD
Practice Address - Street 2:SUITE 218
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7220
Practice Address - Country:US
Practice Address - Phone:707-752-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health