Healthcare Provider Details

I. General information

NPI: 1538756515
Provider Name (Legal Business Name): JENNY KETTERER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNY BUSBY

II. Dates (important events)

Enumeration Date: 12/24/2020
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 COMMERCE ROAD STE 223
JACKSONVILLE NC
28546
US

IV. Provider business mailing address

2440 COMMERCE ROAD STE 223
JACKSONVILLE NC
28546
US

V. Phone/Fax

Practice location:
  • Phone: 910-459-9303
  • Fax:
Mailing address:
  • Phone: 910-459-9303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC016074
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: