Provider Demographics
NPI:1841903853
Name:JETT, ANTIQUE
Entity type:Individual
Prefix:
First Name:ANTIQUE
Middle Name:
Last Name:JETT
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 1:1301 E ORANGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:936 MIDDLEBOROUGH RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-5942
Practice Address - Country:US
Practice Address - Phone:443-766-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician