Provider Demographics
NPI:1093496572
Name:JETT, RICHARD ALAN
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALAN
Last Name:JETT
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 1:6039 SW GRAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-3958
Mailing Address - Country:US
Mailing Address - Phone:541-659-9456
Mailing Address - Fax:
Practice Address - Street 1:6039 SW GRAND OAKS DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-3958
Practice Address - Country:US
Practice Address - Phone:541-659-9456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach