Provider Demographics
NPI:1487129987
Name:KETCHUM, BEVERLY JEAN (CPD CLD)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JEAN
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:CPD CLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4756 W 163RD ST
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2821
Mailing Address - Country:US
Mailing Address - Phone:424-240-6505
Mailing Address - Fax:
Practice Address - Street 1:4725 W 163RD ST
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2822
Practice Address - Country:US
Practice Address - Phone:424-240-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2012-257374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula