Healthcare Provider Details

I. General information

NPI: 1609087402
Provider Name (Legal Business Name): JAMIE L. KETTERMAN RN, BSN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax:
Mailing address:
  • Phone: 660-885-8171
  • Fax: 660-890-8422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number2000162289
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2014022528
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: