Provider Demographics
NPI:1760728539
Name:JETT, SUSANNA TINGLE
Entity Type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:TINGLE
Last Name:JETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2807
Mailing Address - Country:US
Mailing Address - Phone:540-371-3467
Mailing Address - Fax:540-371-4626
Practice Address - Street 1:233 FERRY RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-2807
Practice Address - Country:US
Practice Address - Phone:540-371-3467
Practice Address - Fax:540-371-4626
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-22
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202000858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist