Provider Demographics
NPI:1649573817
Name:JOHNSON, JETTIE MARIE
Entity Type:Individual
Prefix:MRS
First Name:JETTIE
Middle Name:MARIE
Last Name:JOHNSON
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 1:2736 ROTHE LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46229-5516
Mailing Address - Country:US
Mailing Address - Phone:317-454-3930
Mailing Address - Fax:
Practice Address - Street 1:2736 ROTHE LN
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:IN
Practice Address - Zip Code:46229-5516
Practice Address - Country:US
Practice Address - Phone:317-454-3930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10-012295-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care