Provider Demographics
NPI:1548805484
Name:LETTMANN, JERRY TYLER
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:TYLER
Last Name:LETTMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6986 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-9639
Mailing Address - Country:US
Mailing Address - Phone:209-966-7095
Mailing Address - Fax:
Practice Address - Street 1:6986 SCOTT RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9639
Practice Address - Country:US
Practice Address - Phone:209-966-7095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator