Provider Demographics
NPI:1386409548
Name:JETTA BLUE LLC
Entity type:Organization
Organization Name:JETTA BLUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-601-6800
Mailing Address - Street 1:3401 CAPITAL AVE SW APT 21A
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-8320
Mailing Address - Country:US
Mailing Address - Phone:269-601-6800
Mailing Address - Fax:
Practice Address - Street 1:3401 CAPITAL AVE SW APT 21A
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-8320
Practice Address - Country:US
Practice Address - Phone:269-601-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care