Provider Demographics
NPI:1265701189
Name:FETTER, JAMIE MARK (ATC)
Entity type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:MARK
Last Name:FETTER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 ARGYLE DR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1821
Mailing Address - Country:US
Mailing Address - Phone:517-265-3726
Mailing Address - Fax:517-264-3869
Practice Address - Street 1:110 S MADISON ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2518
Practice Address - Country:US
Practice Address - Phone:517-264-3969
Practice Address - Fax:517-264-3869
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL20705042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer