MEDICARE: ALLISON DENISE JETER MS, RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT80996	TX
2	133V00000X	Registered Dietitian		MI

General Provider Information

NPI Number	:	1285934307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON DENISE JETER MS, RD, LD

Provider Business Mailing Address
First Line	:	2948 RENFREW ST
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-1454
Country	:	US
Telephone Number	:	936-689-0904
Fax Number	:

Provider Business Practice Location Address
First Line	:	2948 RENFREW ST
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-1454
Country	:	US
Telephone Number	:	936-689-0904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	09/07/2011

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