Provider Demographics
NPI:1750624805
Name:JETTER, KRISTIE MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIE
Middle Name:MICHELLE
Last Name:JETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:MICHELLE
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12901 BRUCE B DOWNS BLVD
Mailing Address - Street 2:MDC 41
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4742
Mailing Address - Country:US
Mailing Address - Phone:813-844-7412
Mailing Address - Fax:
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-272-2244
Practice Address - Fax:813-272-3766
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1307582084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program