Provider Demographics
NPI:1760007272
Name:JETT, JAY ROBERT
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ROBERT
Last Name:JETT
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 1:1600 SW ARCHER RD
Mailing Address - Street 2:BOX 100286
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0286
Mailing Address - Country:US
Mailing Address - Phone:352-265-0761
Mailing Address - Fax:352-265-1060
Practice Address - Street 1:25807 NW 122ND AVE
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-5025
Practice Address - Country:US
Practice Address - Phone:352-316-5492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113440363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program