Provider Demographics
NPI:1063542371
Name:KETTERLING, JAN E (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:E
Last Name:KETTERLING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17975 79TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075
Mailing Address - Country:US
Mailing Address - Phone:701-642-6655
Mailing Address - Fax:
Practice Address - Street 1:2400 ST FRANCIS DRIVE
Practice Address - Street 2:HOPE UNIT ST FRANCIS MEDICAL CENTER
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520
Practice Address - Country:US
Practice Address - Phone:218-643-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN LP 4296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
056M4KEOtherBHSI
11882OtherNDMA