Provider Demographics
NPI:1043516925
Name:KETTERING, JACK (MA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KETTERING
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 CARTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-2630
Mailing Address - Country:US
Mailing Address - Phone:480-543-0038
Mailing Address - Fax:
Practice Address - Street 1:930 W HILL FIELD RD
Practice Address - Street 2:A
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4662
Practice Address - Country:US
Practice Address - Phone:801-366-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health