Provider Demographics
NPI:1811515562
Name:JETTINGHOFF, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:JETTINGHOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 W US HIGHWAY 224
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8305
Mailing Address - Country:US
Mailing Address - Phone:419-448-0220
Mailing Address - Fax:
Practice Address - Street 1:3101 W US HIGHWAY 224
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8305
Practice Address - Country:US
Practice Address - Phone:419-448-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist