Basic Information
| Provider Information | |||||||||
| NPI: | 1831826049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTNER | ||||||||
| FirstName: | JORDYN | ||||||||
| MiddleName: | TERESE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3804 HILLTOP AVE | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155514900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4801 E LINWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641282226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168614700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2022 | ||||||||
| LastUpdateDate: | 08/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 2138440 | WI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.