Healthcare Provider Details

I. General information

NPI: 1164998050
Provider Name (Legal Business Name): JETTA PLOTKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE B122
DALLAS TX
75230-6806
US

IV. Provider business mailing address

7777 FOREST LN STE B122
DALLAS TX
75230-6806
US

V. Phone/Fax

Practice location:
  • Phone: 972-383-1060
  • Fax: 972-383-1061
Mailing address:
  • Phone: 972-383-1060
  • Fax: 972-383-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number636799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: