=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043938277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN B JETTER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 10/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 OLD US HIGHWAY 91
-----------------------------------------------------
City | ULM
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59485-9712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-621-5968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 OLD US HIGHWAY 91
-----------------------------------------------------
City | ULM
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59485-9712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PHA-PHA-LIC-58768
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------