Provider Demographics
NPI:1811641590
Name:JETT, TARA ANNE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANNE
Last Name:JETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 FRONT ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1302
Practice Address - Country:US
Practice Address - Phone:304-514-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant