Provider Demographics
NPI:1639801103
Name:JETTER, MICHELLE T
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:T
Last Name:JETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2629
Mailing Address - Country:US
Mailing Address - Phone:607-432-2000
Mailing Address - Fax:
Practice Address - Street 1:1 NORTON AVE
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2629
Practice Address - Country:US
Practice Address - Phone:607-432-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011028224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant