Provider Demographics
NPI:1003643222
Name:JETMORE, ALYSSA LEE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LEE
Last Name:JETMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4131
Mailing Address - Country:US
Mailing Address - Phone:970-773-3032
Mailing Address - Fax:
Practice Address - Street 1:1410 BONITA AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1909
Practice Address - Country:US
Practice Address - Phone:510-526-4765
Practice Address - Fax:510-526-2887
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker