MEDICARE: FRANCIS PAUL JETTE SOCIAL WORKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	B21394	IN
2	1041C0700X	Clinical Social Worker	2469	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1417900341	OTHER		US ARMY

General Provider Information

NPI Number	:	1417900341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRANCIS PAUL JETTE SOCIAL WORKER

Provider Business Mailing Address
First Line	:	1134 NW MAPLE AVE
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73507-4609
Country	:	US
Telephone Number	:	580-678-1070
Fax Number	:	580-442-7950

Provider Business Practice Location Address
First Line	:	4301 WILSON STREET
Second Line	:	RAHC SUDCC
City	:	FORT SILL
State	:	OK
Zip	:	73503-6300
Country	:	US
Telephone Number	:	580-558-8432
Fax Number	:	580-442-7950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/21/2022

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