Healthcare Provider Details

I. General information

NPI: 1750576815
Provider Name (Legal Business Name): JETTY PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 TUSCALOOSA AVE SW SUITE 110
BIRMINGHAM AL
35211-1416
US

IV. Provider business mailing address

PO BOX 382664
BIRMINGHAM AL
35238-2664
US

V. Phone/Fax

Practice location:
  • Phone: 205-785-2000
  • Fax: 205-785-2945
Mailing address:
  • Phone: 205-785-2000
  • Fax: 205-785-2954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PRAVEEN JETTY
Title or Position: OWNER/M.D.
Credential: M.D.
Phone: 205-785-2000