Provider Demographics
NPI:1851934335
Name:JT ANESTHESIA PROF LLC
Entity Type:Organization
Organization Name:JT ANESTHESIA PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANN MEDORI
Authorized Official - Last Name:HEINRICH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:302-420-9101
Mailing Address - Street 1:32521 139TH STREET
Mailing Address - Street 2:
Mailing Address - City:BOWDLE
Mailing Address - State:SD
Mailing Address - Zip Code:57428
Mailing Address - Country:US
Mailing Address - Phone:302-420-9101
Mailing Address - Fax:
Practice Address - Street 1:32521 139TH STREET
Practice Address - Street 2:
Practice Address - City:BOWDLE
Practice Address - State:SD
Practice Address - Zip Code:57428
Practice Address - Country:US
Practice Address - Phone:302-420-9101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty