Provider Demographics
NPI:1982320685
Name:KETTELL, JESSICA NOEL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NOEL
Last Name:KETTELL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 SUGARLOAF PKWY STE 1108
Mailing Address - Street 2:STE 1108 #6383
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7832
Mailing Address - Country:US
Mailing Address - Phone:678-818-3129
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY STE 221
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1723
Practice Address - Country:US
Practice Address - Phone:888-588-8995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN255108363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty