Provider Demographics
NPI:1669681029
Name:JETT, MICKEY D (MDIVL, MS)
Entity Type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:D
Last Name:JETT
Suffix:
Gender:M
Credentials:MDIVL, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 EMDEN HOLLOW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247
Mailing Address - Country:US
Mailing Address - Phone:210-653-1688
Mailing Address - Fax:
Practice Address - Street 1:HHC, 82D SUS BDE
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09331
Practice Address - Country:IQ
Practice Address - Phone:318-833-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NBCC77094101Y00000X
TXAAPC10958101YP1600X
AAMFT101247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist