Provider Demographics
NPI:1306157508
Name:KETTERMAN, JENNIFER BEARE (FNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BEARE
Last Name:KETTERMAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 HAYMAN DR
Mailing Address - Street 2:
Mailing Address - City:FEDERALSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21632-2626
Mailing Address - Country:US
Mailing Address - Phone:410-754-2440
Mailing Address - Fax:
Practice Address - Street 1:3304 HAYMAN DR
Practice Address - Street 2:
Practice Address - City:FEDERALSBURG
Practice Address - State:MD
Practice Address - Zip Code:21632
Practice Address - Country:US
Practice Address - Phone:410-754-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000834363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1306157508Medicaid
192082YZCMedicare PIN