Provider Demographics
NPI:1902884661
Name:KETCHAM, JON MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MARK
Last Name:KETCHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2546
Mailing Address - Country:US
Mailing Address - Phone:814-337-0128
Mailing Address - Fax:814-337-0164
Practice Address - Street 1:765 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2546
Practice Address - Country:US
Practice Address - Phone:814-337-0128
Practice Address - Fax:814-337-0164
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006808L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA163160OtherHIGHMARK MEDICARE SREVICES
PA205078OtherUPMC
PAKE596806OtherBLUE CROSS / BLUE SHIELD
PA001616400 0006Medicaid
PA205078OtherUPMC