Provider Demographics
NPI:1114013794
Name:JETT, LAURA LEA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEA
Last Name:JETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 ESSEX RD
Mailing Address - Street 2:LAHEY HEALTH PRIMARY CARE, IPSWICH
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-2599
Mailing Address - Country:US
Mailing Address - Phone:978-356-5522
Mailing Address - Fax:
Practice Address - Street 1:36 ESSEX RD
Practice Address - Street 2:LAHEY HEALTH PRIMARY CARE, IPSWICH
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-2599
Practice Address - Country:US
Practice Address - Phone:978-356-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015052207Q00000X
MA257310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110102085AMedicaid
ME135160099Medicaid
MAS400364459Medicare PIN
MEMM730001Medicare PIN