Provider Demographics
NPI:1770046617
Name:JETT, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W COUGAR BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3334
Mailing Address - Country:US
Mailing Address - Phone:801-357-8586
Mailing Address - Fax:801-357-7786
Practice Address - Street 1:395 W COUGAR BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3334
Practice Address - Country:US
Practice Address - Phone:801-357-8586
Practice Address - Fax:801-357-7786
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13248644-1205207Q00000X, 207RH0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program