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General NPI Number Information
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NPI Number | 1003684119
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Entity Type | Individual
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Provider Name | JACQUELINE GRACE KETTLER OTR/L
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Gender | Female
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Dates
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Enumeration Date | 12/18/2023
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Last Update Date | 12/18/2023
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Provider Practice Location Address
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Address Line | 150 VILLAGE CROSSING CT
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32084-8697
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Country | US
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Telephone | 502-694-5241
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Fax |
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Provider Business Mailing Address
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Address Line | 2121 GOLDEN LAKE LOOP
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32084-5899
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Country | US
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Telephone | 417-385-7650
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 23228
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License Number State | FL
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