Provider Demographics
NPI:1710499397
Name:JETTON, TAMMY MICHELE (MED)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MICHELE
Last Name:JETTON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:MICHELE
Other - Last Name:JETTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:202 FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5223
Mailing Address - Country:US
Mailing Address - Phone:702-349-4194
Mailing Address - Fax:
Practice Address - Street 1:202 FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-5223
Practice Address - Country:US
Practice Address - Phone:702-349-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor