Provider Demographics
NPI:1831689694
Name:KETNER, JACKI (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACKI
Middle Name:
Last Name:KETNER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EVES DR STE A100
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3126
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:609-267-9457
Practice Address - Street 1:570 EGG HARBOR RD STE C4
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2359
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:609-267-9457
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01691700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01691700OtherPROFESSIONAL LICENSE