Provider Demographics
NPI:1104073519
Name:ALMON, JETTA L (CST, CSFA)
Entity type:Individual
Prefix:
First Name:JETTA
Middle Name:L
Last Name:ALMON
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 SE RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1166
Mailing Address - Country:US
Mailing Address - Phone:812-484-2689
Mailing Address - Fax:
Practice Address - Street 1:1207 SE RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1166
Practice Address - Country:US
Practice Address - Phone:812-484-2689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN95829246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001069797OtherANTHEM BCBS
IN4116028OtherAETNA
KY000000085654OtherKENTUCKY BLUE CROSS BLUE SHIELD
IN221001OtherWELBORN HEALTHCARE
IL91107974OtherILLINOIS BLUE CROSS BLUE SHIELD
IN000000085654OtherINDIANA BLUE CROSS BLUE SHIELD