Provider Demographics
NPI:1669847778
Name:JEANTY, JEAN MICHELET (PA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MICHELET
Last Name:JEANTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 RALPH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5610
Mailing Address - Country:US
Mailing Address - Phone:615-525-1741
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019258363A00000X
PAMA058025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant