Healthcare Provider Details

I. General information

NPI: 1437100484
Provider Name (Legal Business Name): PHYLLIS J JETER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 REDMOND CIR NW
ROME GA
30165-1307
US

IV. Provider business mailing address

PO BOX 538622
ATLANTA GA
30353-8622
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-535-1211
  • Fax: 919-746-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW002331
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: