Provider Demographics
NPI:1376838433
Name:JETTY, AMANDA MARY (DPT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARY
Last Name:JETTY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4477
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:5424 DISCOVERY PARK BLVD
Practice Address - Street 2:BLDG. B /STE. 101
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188
Practice Address - Country:US
Practice Address - Phone:757-345-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208434225100000X
NC13158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist