MEDICARE: JANUARY JETER LSW

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	1041C0700X	Clinical Social Worker	34008821A	IN
2	104100000X	Social Worker		IN

General Provider Information

NPI Number	:	1487133039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANUARY JETER LSW

Provider Business Mailing Address
First Line	:	PO BOX 637764
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-7764
Country	:	US
Telephone Number	:	317-880-3939
Fax Number	:

Provider Business Practice Location Address
First Line	:	4712 E 55TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5702
Country	:	US
Telephone Number	:	317-603-7283
Fax Number	:

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

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	09/22/2025

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