Healthcare Provider Details

I. General information

NPI: 1184384257
Provider Name (Legal Business Name): JETTISON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 E ORCHARD RD STE B
LITTLETON CO
80121-8055
US

IV. Provider business mailing address

45 PORTLAND RD STE 7-226
KENNEBUNK ME
04043-6660
US

V. Phone/Fax

Practice location:
  • Phone: 303-493-9509
  • Fax:
Mailing address:
  • Phone: 207-292-6261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT AYALA
Title or Position: PRESIDENT
Credential:
Phone: 212-321-0477