Healthcare Provider Details

I. General information

NPI: 1295185577
Provider Name (Legal Business Name): ERNEST JETER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S SYCAMORE ST STE B
PETERSBURG VA
23803-4279
US

IV. Provider business mailing address

1640 JOHNSON RD SUITE 114B
PETERSBURG VA
23805-1272
US

V. Phone/Fax

Practice location:
  • Phone: 347-596-7357
  • Fax: 804-479-3373
Mailing address:
  • Phone: 347-596-7357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberPPS-0605341
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: