Provider Demographics
NPI:1275632218
Name:JETTIE, RONALD CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:CHARLES
Last Name:JETTIE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30405 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334
Mailing Address - Country:US
Mailing Address - Phone:248-477-5255
Mailing Address - Fax:248-474-4383
Practice Address - Street 1:30405 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-477-5255
Practice Address - Fax:248-474-4383
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004377111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF35161OtherBCBS
MIOF35161Medicare ID - Type Unspecified
T33385Medicare UPIN