Provider Demographics
NPI:1912626409
Name:JEANTY, KUTHZIE MAIKA
Entity Type:Individual
Prefix:
First Name:KUTHZIE
Middle Name:MAIKA
Last Name:JEANTY
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 1:51 GRAFTON AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-5554
Mailing Address - Country:US
Mailing Address - Phone:937-824-0138
Mailing Address - Fax:
Practice Address - Street 1:51 GRAFTON AVE APT 203
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-5554
Practice Address - Country:US
Practice Address - Phone:937-824-0138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025147225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist