Provider Demographics
NPI:1215280250
Name:JETTON, RENA MONIQUE (MS)
Entity type:Individual
Prefix:MS
First Name:RENA
Middle Name:MONIQUE
Last Name:JETTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5361 N PERSHING AVE STE H
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5450
Mailing Address - Country:US
Mailing Address - Phone:209-477-9177
Mailing Address - Fax:209-477-4667
Practice Address - Street 1:5361 N PERSHING AVE STE H
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5450
Practice Address - Country:US
Practice Address - Phone:209-477-9177
Practice Address - Fax:209-477-4667
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst