Provider Demographics
NPI:1043938277
Name:JETTER, JONATHAN B
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:JETTER
Suffix:
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 1:210 OLD US HIGHWAY 91
Mailing Address - Street 2:
Mailing Address - City:ULM
Mailing Address - State:MT
Mailing Address - Zip Code:59485-9712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 OLD US HIGHWAY 91
Practice Address - Street 2:
Practice Address - City:ULM
Practice Address - State:MT
Practice Address - Zip Code:59485-9712
Practice Address - Country:US
Practice Address - Phone:937-621-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-58768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist