Healthcare Provider Details

I. General information

NPI: 1053216382
Provider Name (Legal Business Name): TRAVIS GENE JETER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 VERA DR
LINCOLN NE
68516-2179
US

IV. Provider business mailing address

7500 VERA DR
LINCOLN NE
68516-2179
US

V. Phone/Fax

Practice location:
  • Phone: 760-508-1225
  • Fax:
Mailing address:
  • Phone: 760-508-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: