Provider Demographics
NPI:1003190174
Name:JETLEY, NIRUPMA (LCDCIII)
Entity type:Individual
Prefix:MRS
First Name:NIRUPMA
Middle Name:
Last Name:JETLEY
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27072 CARRONADE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5300
Mailing Address - Country:US
Mailing Address - Phone:419-872-2419
Mailing Address - Fax:419-720-5223
Practice Address - Street 1:27072 CARRONADE DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5300
Practice Address - Country:US
Practice Address - Phone:419-872-2419
Practice Address - Fax:419-720-5223
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH031085101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)