Provider Demographics
NPI:1003206707
Name:JETT, RICCI I
Entity Type:Individual
Prefix:
First Name:RICCI
Middle Name:
Last Name:JETT
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 NW EXPRESSWAY
Mailing Address - Street 2:250
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5239
Mailing Address - Country:US
Mailing Address - Phone:405-476-3672
Mailing Address - Fax:
Practice Address - Street 1:5830 NW EXPRESSWAY
Practice Address - Street 2:250
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5239
Practice Address - Country:US
Practice Address - Phone:405-476-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator