1376167080 NPI number — MRS. MELINDA JANE JETTER R.N.

Table of content: MRS. MELINDA JANE JETTER R.N. (NPI 1376167080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376167080 NPI number — MRS. MELINDA JANE JETTER R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JETTER
Provider First Name:
MELINDA
Provider Middle Name:
JANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.N.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
MELINDA
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376167080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
351 NORTON ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-265-9646
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 NORTH WILLOW AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-520-7763
Provider Business Practice Location Address Fax Number:
931-646-4866
Provider Enumeration Date:
05/29/2020

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: 163WH0500X , with the licence number:  RN0000177130 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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