Provider Demographics
NPI:1902664204
Name:KETCHEM, JACLYN NICOLE (MFT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:KETCHEM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:NICOLE
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1793 GOLDEN OAKS RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:15341-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 WHITE WILLOW WAY
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-6119
Practice Address - Country:US
Practice Address - Phone:304-212-7238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist