Provider Demographics
NPI:1457749046
Name:KETNER, JASON BROOK (CCC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BROOK
Last Name:KETNER
Suffix:
Gender:M
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 NEW CAMPFIRE RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-8342
Mailing Address - Country:US
Mailing Address - Phone:618-303-1730
Mailing Address - Fax:
Practice Address - Street 1:36430 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1330
Practice Address - Country:US
Practice Address - Phone:727-330-0420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty