Provider Demographics
NPI:1720366826
Name:JETT, MAIRIN (APRN)
Entity type:Individual
Prefix:
First Name:MAIRIN
Middle Name:
Last Name:JETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4205
Mailing Address - Country:US
Mailing Address - Phone:502-822-6603
Mailing Address - Fax:502-747-7071
Practice Address - Street 1:506 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4205
Practice Address - Country:US
Practice Address - Phone:502-822-6603
Practice Address - Fax:502-747-7071
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007025363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101019140Medicaid
IN300082585Medicaid