Provider Demographics
NPI:1194100669
Name:PATTERSON, JETTIE MAE
Entity type:Individual
Prefix:
First Name:JETTIE
Middle Name:MAE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 TULANE DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8006
Mailing Address - Country:US
Mailing Address - Phone:910-257-7189
Mailing Address - Fax:910-281-2056
Practice Address - Street 1:131 TULANE DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8006
Practice Address - Country:US
Practice Address - Phone:910-257-7189
Practice Address - Fax:910-281-2056
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes252Y00000XAgenciesEarly Intervention Provider Agency