Provider Demographics
NPI:1023565389
Name:JETTE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 NW 69TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1236
Mailing Address - Country:US
Mailing Address - Phone:954-495-6085
Mailing Address - Fax:
Practice Address - Street 1:3147 NW 69TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1236
Practice Address - Country:US
Practice Address - Phone:954-495-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-04
Last Update Date:2016-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLORIDAMedicaid