Provider Demographics
NPI:1225522634
Name:JETT, AMANDA C
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:JETT
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 1:575 WESTAR XING STE 101
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7815
Mailing Address - Country:US
Mailing Address - Phone:614-508-2223
Mailing Address - Fax:
Practice Address - Street 1:575 WESTAR XING STE 101
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7815
Practice Address - Country:US
Practice Address - Phone:614-508-2223
Practice Address - Fax:614-508-2233
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics