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General NPI Number Information
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NPI Number | 1619357837
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Entity Type | Individual
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Provider Name | RESEAN JETSON
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Gender | Male
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Dates
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Enumeration Date | 06/03/2015
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Last Update Date | 10/26/2023
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Provider Practice Location Address
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Address Line | 4014 N HAMPTON DR
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City | POWELL
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State | OH
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Zip | 43065-8431
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Country | US
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Telephone | 614-470-4466
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Fax | 614-626-5301
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Provider Business Mailing Address
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Address Line | 4014 N HAMPTON DR
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City | POWELL
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State | OH
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Zip | 43065-8431
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Country | US
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Telephone | 614-470-4466
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Fax | 614-355-2220
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | P.08556
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License Number State | OH
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