Provider Demographics
NPI:1588153050
Name:JETT, JOE MELVIN JR (DPH)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:MELVIN
Last Name:JETT
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 MOORESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:CULLEOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38451-8030
Mailing Address - Country:US
Mailing Address - Phone:931-637-6572
Mailing Address - Fax:
Practice Address - Street 1:2130 N LOCUST AVE # 931
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-4456
Practice Address - Country:US
Practice Address - Phone:931-762-6058
Practice Address - Fax:931-762-6013
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3003OtherPHARMACIST
TN3003OtherPHARMACIST LICENSE