Provider Demographics
NPI:1619357837
Name:JETSON, RESEAN
Entity Type:Individual
Prefix:
First Name:RESEAN
Middle Name:
Last Name:JETSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RESEAN
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4014 N HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8431
Mailing Address - Country:US
Mailing Address - Phone:614-470-4466
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:4014 N HAMPTON DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8431
Practice Address - Country:US
Practice Address - Phone:614-470-4466
Practice Address - Fax:614-626-5301
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08556103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid