Provider Demographics
NPI:1922234509
Name:JAMISON, GRETTA A (IDMT)
Entity Type:Individual
Prefix:
First Name:GRETTA
Middle Name:A
Last Name:JAMISON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-0778
Mailing Address - Fax:937-522-2128
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-0778
Practice Address - Fax:937-522-2128
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians