Provider Demographics
NPI:1497383046
Name:EMMETT, JESSY ROY (HIS)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:ROY
Last Name:EMMETT
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WEST STATE STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670
Mailing Address - Country:US
Mailing Address - Phone:812-385-0112
Mailing Address - Fax:
Practice Address - Street 1:205 WEST STATE STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670
Practice Address - Country:US
Practice Address - Phone:812-385-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001528A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty