MEDICARE: JETTISON MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	207R00000X	Internal Medicine Physician
3	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1457239691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JETTISON MEDICAL GROUP

Provider Business Mailing Address
First Line	:	600 17TH ST STE 2883
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80202-5402
Country	:	US
Telephone Number	:	303-493-9509
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 17TH ST STE 2883
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80202-5402
Country	:	US
Telephone Number	:	303-493-9509
Fax Number	:

Authorized Official
Title or Position	:	PC OWNER
Name	:	SONJAY SHRINIVAS
Credential	:	DO
Telephone Number	:	617-504-4449

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	08/25/2025

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