Basic Information
| Provider Information | |||||||||
| NPI: | 1396994869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JETTE-KELLY | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680208 | ||||||||
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| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680208 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 15574 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RP1001X | MD60923760 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.