Healthcare Provider Details

I. General information

NPI: 1710381314
Provider Name (Legal Business Name): ALLEN JETER DD,MAC,CDDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2014
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2942 N 24TH ST 114-766
PHOENIX AZ
85016-7844
US

IV. Provider business mailing address

2942 N 24TH ST 114-766
PHOENIX AZ
85016-7844
US

V. Phone/Fax

Practice location:
  • Phone: 480-521-4815
  • Fax: 602-424-5757
Mailing address:
  • Phone: 480-521-4815
  • Fax: 623-242-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number86520
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: