Provider Demographics
NPI:1306275995
Name:KETCHUM, JORI
Entity type:Individual
Prefix:
First Name:JORI
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4036
Mailing Address - Country:US
Mailing Address - Phone:580-326-5279
Mailing Address - Fax:580-326-8047
Practice Address - Street 1:211 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4036
Practice Address - Country:US
Practice Address - Phone:580-326-5279
Practice Address - Fax:580-326-8047
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200493040AMedicaid