Healthcare Provider Details

I. General information

NPI: 1912839192
Provider Name (Legal Business Name): XAVIER KY JETER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 UNIVERSITY AVE APT 6D
BRONX NY
10468-2363
US

IV. Provider business mailing address

2855 UNIVERSITY AVE APT 6D
BRONX NY
10468-2363
US

V. Phone/Fax

Practice location:
  • Phone: 929-764-6354
  • Fax:
Mailing address:
  • Phone: 929-764-6354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: