Provider Demographics
NPI:1861278400
Name:SMITH, KATHERINE JAYNE KETTLER (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JAYNE KETTLER
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:JAYNE
Other - Last Name:KETTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:670 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1973
Mailing Address - Country:US
Mailing Address - Phone:801-266-3979
Mailing Address - Fax:
Practice Address - Street 1:670 E 3900 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-1973
Practice Address - Country:US
Practice Address - Phone:801-266-3979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6547402-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist