1083758759 NPI number — MRS. KRISTA SEBERT JETT M.S., CCC-SLP

Table of content: MRS. KRISTA SEBERT JETT M.S., CCC-SLP (NPI 1083758759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083758759 NPI number — MRS. KRISTA SEBERT JETT M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JETT
Provider First Name:
KRISTA
Provider Middle Name:
SEBERT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083758759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 MARION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26554-2362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-288-3607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1160 VAN VOORHIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-363-5235
Provider Business Practice Location Address Fax Number:
304-363-5880
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP-0913 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810002023 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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