Provider Demographics
NPI:1689026015
Name:ANDERSON, JETTA (CPM)
Entity Type:Individual
Prefix:
First Name:JETTA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 E AVENIDA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-8601
Mailing Address - Country:US
Mailing Address - Phone:602-717-3731
Mailing Address - Fax:
Practice Address - Street 1:2018 E AVENIDA DEL SOL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-8601
Practice Address - Country:US
Practice Address - Phone:602-717-3731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16060006176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife