Provider Demographics
NPI:1427497437
Name:JETT, KEISHA (RN)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:JETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-2360
Mailing Address - Country:US
Mailing Address - Phone:419-973-7660
Mailing Address - Fax:
Practice Address - Street 1:621 GREENE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-2360
Practice Address - Country:US
Practice Address - Phone:419-973-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH448820163W00000X
OH143915164W00000X
385H00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086239Medicaid