Provider Demographics
NPI:1265749048
Name:JETTY, MARGARET K (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:K
Last Name:JETTY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:K
Other - Last Name:JETTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1350 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-4537
Mailing Address - Country:US
Mailing Address - Phone:480-286-8720
Mailing Address - Fax:
Practice Address - Street 1:1350 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-4537
Practice Address - Country:US
Practice Address - Phone:602-452-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP6968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist