Healthcare Provider Details

I. General information

NPI: 1104361534
Provider Name (Legal Business Name): TODD B. JETER LCSW, CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 WILLAMETTE ST STE 3
EUGENE OR
97401-4087
US

IV. Provider business mailing address

PO BOX 40142
EUGENE OR
97404-0020
US

V. Phone/Fax

Practice location:
  • Phone: 541-234-3090
  • Fax: 541-735-9480
Mailing address:
  • Phone: 541-234-3090
  • Fax: 541-735-9480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16-11-18
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19-01-20
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL10427
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500731705
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500725923
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: