Provider Demographics
NPI:1083758759
Name:JETT, KRISTA SEBERT (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:SEBERT
Last Name:JETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2362
Mailing Address - Country:US
Mailing Address - Phone:304-288-3607
Mailing Address - Fax:
Practice Address - Street 1:1160 VAN VOORHIS RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3437
Practice Address - Country:US
Practice Address - Phone:304-363-5235
Practice Address - Fax:304-363-5880
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002023Medicaid