Provider Demographics
NPI:1568908416
Name:JETT, AMANDA KATHLEEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:JETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KATHLEEN
Other - Last Name:SINISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6071 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-4758
Practice Address - Country:US
Practice Address - Phone:314-687-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016039167363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty