Provider Demographics
NPI:1386623825
Name:JETT, MICHAEL J (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:JETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 AUSTIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4731
Mailing Address - Country:US
Mailing Address - Phone:718-997-0444
Mailing Address - Fax:718-997-0443
Practice Address - Street 1:7306 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6251
Practice Address - Country:US
Practice Address - Phone:718-997-0444
Practice Address - Fax:718-997-0443
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06800GMedicare ID - Type UnspecifiedCHIROPRACTOR