Healthcare Provider Details

I. General information

NPI: 1497261598
Provider Name (Legal Business Name): ERNEST JETER, MSED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 12/27/2017
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 APT 114B
PETERSBURG VA
23805-1258
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: ERNEST JETER
Title or Position: OWNER
Credential: MSED
Phone: 347-596-7357