Provider Demographics
NPI:1356569933
Name:KETO, JESSICA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:KETO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:KELM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:250 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-5714
Practice Address - Fax:616-685-5260
Is Sole Proprietor?:No
Enumeration Date:2007-04-21
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085967208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32930405Medicare PIN