Healthcare Provider Details

I. General information

NPI: 1750742201
Provider Name (Legal Business Name): ROSE R JETER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 05/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 804-835-9511
  • Fax: 804-479-3373
Mailing address:
  • Phone: 804-835-9511
  • Fax: 804-479-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009125
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number083428
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: