Provider Demographics
NPI:1619282878
Name:NETTER, JASANDA WYKETTA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JASANDA
Middle Name:WYKETTA
Last Name:NETTER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 ROSEMARY RD
Mailing Address - Street 2:APT. # 39
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2053
Mailing Address - Country:US
Mailing Address - Phone:662-719-1825
Mailing Address - Fax:
Practice Address - Street 1:607 ROSEMARY RD
Practice Address - Street 2:APT. # 39
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2053
Practice Address - Country:US
Practice Address - Phone:662-719-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04471273Medicaid