Provider Demographics
NPI:1184384257
Name:JETTISON, INC.
Entity type:Organization
Organization Name:JETTISON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-321-0477
Mailing Address - Street 1:45 PORTLAND RD STE 7-226
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6660
Mailing Address - Country:US
Mailing Address - Phone:207-292-6261
Mailing Address - Fax:
Practice Address - Street 1:600 17TH STREET
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-5428
Practice Address - Country:US
Practice Address - Phone:303-260-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty