Healthcare Provider Details

I. General information

NPI: 1851924237
Provider Name (Legal Business Name): JETER SPEECH LANGUAGE PATHOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/08/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E 70TH ST STE A
SHREVEPORT LA
71105-5345
US

IV. Provider business mailing address

1950 E 70TH ST STE A
SHREVEPORT LA
71105-5345
US

V. Phone/Fax

Practice location:
  • Phone: 318-219-6064
  • Fax: 318-225-7928
Mailing address:
  • Phone: 318-219-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DANA RENE WILLIAMS
Title or Position: OWNER
Credential: MCD/CCC-SLP
Phone: 337-718-3404