Healthcare Provider Details

I. General information

NPI: 1972423648
Provider Name (Legal Business Name): EDWARD TEDDY JETER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 INDEPENDENCE SQ
WEST PLAINS MO
65775-4224
US

IV. Provider business mailing address

2108 INDEPENDENCE SQ
WEST PLAINS MO
65775-4224
US

V. Phone/Fax

Practice location:
  • Phone: 417-293-4875
  • Fax:
Mailing address:
  • Phone: 417-293-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2026023618
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: