MEDICARE: JEANNE MOORE-KETTELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1801107719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNE MOORE-KETTELL

Provider Business Mailing Address
First Line	:	11901 BUSINESS BLVD
Second Line	:	SUITE 209
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7701
Country	:	US
Telephone Number	:	907-694-6002
Fax Number	:	907-694-6022

Provider Business Practice Location Address
First Line	:	11901 BUSINESS BLVD
Second Line	:	SUITE 209
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7701
Country	:	US
Telephone Number	:	907-694-6002
Fax Number	:	907-694-6022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2010
Last Update Date	:	06/24/2010

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Directions to “ JEANNE MOORE-KETTELL ” Practice Location

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