Provider Demographics
NPI:1174766943
Name:KETTERLY, JENNIFER E (MS, RD, LDN)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:E
Last Name:KETTERLY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LAKE HILL DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-8955
Mailing Address - Country:US
Mailing Address - Phone:919-484-0327
Mailing Address - Fax:
Practice Address - Street 1:THE JAMES A. TAYLOR STUDENT HEALTH SERVICES CB#7470
Practice Address - Street 2:THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-7470
Practice Address - Country:US
Practice Address - Phone:919-962-9356
Practice Address - Fax:919-843-4771
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered