Healthcare Provider Details

I. General information

NPI: 1194653857
Provider Name (Legal Business Name): CARL DARNELL JETER II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 11TH ST NW
CANTON OH
44703-2127
US

IV. Provider business mailing address

1416 11TH ST NW
CANTON OH
44703-2127
US

V. Phone/Fax

Practice location:
  • Phone: 330-327-2716
  • Fax:
Mailing address:
  • Phone: 330-327-2716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberST131190
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: