Provider Demographics
NPI:1669587390
Name:JETT, SUSAN MICHELLE (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MICHELLE
Last Name:JETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:601 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9005
Mailing Address - Country:US
Mailing Address - Phone:601-932-5654
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-364-1285
Practice Address - Fax:601-364-1257
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR668001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily