Healthcare Provider Details

I. General information

NPI: 1043938277
Provider Name (Legal Business Name): JONATHAN B JETTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 OLD US HIGHWAY 91
ULM MT
59485-9712
US

IV. Provider business mailing address

210 OLD US HIGHWAY 91
ULM MT
59485-9712
US

V. Phone/Fax

Practice location:
  • Phone: 937-621-5968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA-PHA-LIC-58768
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: