Provider Demographics
NPI:1467640649
Name:JETTON, WENDY KAE (CSA)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:KAE
Last Name:JETTON
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 RANDALL CT NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4724
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2016-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1256363AS0400X
TX031113246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA264408800Medicare PIN