Healthcare Provider Details

I. General information

NPI: 1861423022
Provider Name (Legal Business Name): GAIL MARIE JETT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 NE MARY ROSE PL SUITE 220
BEND OR
97701-7132
US

IV. Provider business mailing address

2450 NE MARY ROSE PL SUITE 220
BEND OR
97701-7132
US

V. Phone/Fax

Practice location:
  • Phone: 541-385-8050
  • Fax:
Mailing address:
  • Phone: 541-385-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number098007266N1
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: