Provider Demographics
NPI:1457717639
Name:KETTERER, JESSICA (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KETTERER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5603
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:603 N FLAMINGO RD
Practice Address - Street 2:SUITE 151
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1023
Practice Address - Country:US
Practice Address - Phone:954-265-4325
Practice Address - Fax:954-443-4747
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist