MEDICARE: DR. MARVIN HOMER JETER JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	05361	MS

General Provider Information

NPI Number	:	1235397423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARVIN HOMER JETER JR. M.D.

Provider Business Mailing Address
First Line	:	15 NORTHTOWN DR
Second Line	:	SUITE G
City	:	JACKSON
State	:	MS
Zip	:	39211-3048
Country	:	US
Telephone Number	:	601-956-8200
Fax Number	:	601-956-8100

Provider Business Practice Location Address
First Line	:	15 NORTHTOWN DR
Second Line	:	SUITE G
City	:	JACKSON
State	:	MS
Zip	:	39211-3048
Country	:	US
Telephone Number	:	601-956-8200
Fax Number	:	601-956-8100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2008
Last Update Date	:	08/26/2015

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