Provider Demographics
NPI:1255670477
Name:JET, PSC
Entity Type:Organization
Organization Name:JET, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:606-271-1920
Mailing Address - Street 1:312 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1165
Mailing Address - Country:US
Mailing Address - Phone:606-271-1920
Mailing Address - Fax:606-451-9465
Practice Address - Street 1:149 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-6155
Practice Address - Country:US
Practice Address - Phone:606-679-6995
Practice Address - Fax:606-451-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLCSW 3155251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP4000.7013Medicare PIN