Healthcare Provider Details

I. General information

NPI: 1720483787
Provider Name (Legal Business Name): DWAYNE OLIVER JETER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2014
Last Update Date: 11/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 4TH ST
ALEXANDRIA LA
71301-8421
US

IV. Provider business mailing address

211 4TH ST
ALEXANDRIA LA
71301-8421
US

V. Phone/Fax

Practice location:
  • Phone: 318-769-3000
  • Fax:
Mailing address:
  • Phone: 318-769-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: