Provider Demographics
NPI:1790728970
Name:JETT, KATHY M (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:M
Last Name:JETT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2073
Mailing Address - Country:US
Mailing Address - Phone:330-364-4600
Mailing Address - Fax:330-364-3338
Practice Address - Street 1:300 MEDICAL PARK DR
Practice Address - Street 2:SUITE 205
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2073
Practice Address - Country:US
Practice Address - Phone:330-364-4600
Practice Address - Fax:330-364-3338
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04286363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2358470Medicaid
OHNP10943Medicare ID - Type Unspecified
OHNP10942Medicare UPIN