Provider Demographics
NPI:1205318672
Name:JETT, JONATHAN D
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:JETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 HUMMINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-2361
Mailing Address - Country:US
Mailing Address - Phone:956-342-3783
Mailing Address - Fax:956-664-9065
Practice Address - Street 1:1301 E QUEBEC AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1623
Practice Address - Country:US
Practice Address - Phone:956-661-4300
Practice Address - Fax:956-664-9065
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2083921225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant