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General NPI Number Information
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NPI Number | 1417408964
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Entity Type | Organization
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Legal Business Name | JETT SURGICAL LLC
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Dates
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Enumeration Date | 10/19/2016
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Last Update Date | 12/12/2016
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Provider Practice Location Address
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Address Line | 915 RANDALL CT NW
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City | MARIETTA
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State | GA
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Zip | 30064-4724
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Country | US
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Telephone | 770-842-1907
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Fax | 678-214-5098
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Provider Business Mailing Address
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Address Line | PO BOX 422252
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City | ATLANTA
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State | GA
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Zip | 30342-9252
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Country | US
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Telephone | 770-842-1907
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Fax | 678-214-5098
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Authorized Official
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Title or Position | CEO
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Name | WENDY KAE JETTON
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Credential | CSA
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Telephone | 770-842-1907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 1256
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License Number State | GA
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