Provider Demographics
NPI:1407854938
Name:JETT, KATHERINE MARIE (FAMILY NURSE PRACT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:JETT
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1200 N STATE ST # LL10
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2000
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-714-3415
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869652363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01489305Medicaid
MS01489305Medicaid