Healthcare Provider Details

I. General information

NPI: 1851934335
Provider Name (Legal Business Name): JT ANESTHESIA PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32521 139TH STREET
BOWDLE SD
57428
US

IV. Provider business mailing address

32521 139TH STREET
BOWDLE SD
57428
US

V. Phone/Fax

Practice location:
  • Phone: 302-420-9101
  • Fax:
Mailing address:
  • Phone: 302-420-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA ANN MEDORI HEINRICH
Title or Position: CRNA
Credential: CRNA
Phone: 302-420-9101