Provider Demographics
NPI:1679154389
Name:FREEMAN, JETTON
Entity Type:Individual
Prefix:
First Name:JETTON
Middle Name:
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15311 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3903
Mailing Address - Country:US
Mailing Address - Phone:216-301-6751
Mailing Address - Fax:
Practice Address - Street 1:4338 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5762
Practice Address - Country:US
Practice Address - Phone:216-301-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT637221174200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals