Provider Demographics
NPI:1316323843
Name:JETT, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JETT
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 1:7128 NANSEN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6730
Mailing Address - Country:US
Mailing Address - Phone:347-453-0344
Mailing Address - Fax:
Practice Address - Street 1:7150 AUSTIN ST STE 103
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4731
Practice Address - Country:US
Practice Address - Phone:347-453-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001271-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health