Basic Information
| Provider Information | |||||||||
| NPI: | 1215601455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEWETT SPORTS & OCCUPATIONAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2302 | ||||||||
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| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475010942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125845700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475018537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125845700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | JEWETT | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE RAMAJ | ||||||||
| AuthorizedOfficialTitleorPosition: | ATHLETIC TRAINER / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8125845700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | ATC | ||||||||
| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.