Provider Demographics
NPI:1417408964
Name:JETT SURGICAL LLC
Entity Type:Organization
Organization Name:JETT SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:KAE
Authorized Official - Last Name:JETTON
Authorized Official - Suffix:
Authorized Official - Credentials:CSA
Authorized Official - Phone:770-842-1907
Mailing Address - Street 1:PO BOX 422252
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-9252
Mailing Address - Country:US
Mailing Address - Phone:770-842-1907
Mailing Address - Fax:678-214-5098
Practice Address - Street 1:915 RANDALL CT NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4724
Practice Address - Country:US
Practice Address - Phone:770-842-1907
Practice Address - Fax:678-214-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1256363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty