Provider Demographics
NPI:1750576815
Name:JETTY PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:JETTY PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-785-2000
Mailing Address - Street 1:PO BOX 382664
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35238-2664
Mailing Address - Country:US
Mailing Address - Phone:205-785-2000
Mailing Address - Fax:205-785-2954
Practice Address - Street 1:401 TUSCALOOSA AVE SW
Practice Address - Street 2:SUITE 110
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1416
Practice Address - Country:US
Practice Address - Phone:205-785-2000
Practice Address - Fax:205-785-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG77250Medicare UPIN