Healthcare Provider Details

I. General information

NPI: 1760007272
Provider Name (Legal Business Name): JAY ROBERT JETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25807 NW 122ND AVE
HIGH SPRINGS FL
32643-5025
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100286
GAINESVILLE FL
32610-0286
US

V. Phone/Fax

Practice location:
  • Phone: 352-316-5492
  • Fax:
Mailing address:
  • Phone: 352-265-0761
  • Fax: 352-265-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113440
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: