MEDICARE: MR. DAVID JETSON LPC - MH

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	101Y00000X	Counselor	LPC-MH2145	SD
2	101YP2500X	Professional Counselor	LPC-MH2145	SD
3	101YM0800X	Mental Health Counselor	LPC-MH2145	SD

General Provider Information

NPI Number	:	1598706749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID JETSON LPC - MH

Provider Business Mailing Address
First Line	:	1301 WEST OMAHA ST.
Second Line	:	SUITE 220
City	:	RAPID CITY
State	:	SD
Zip	:	57701-4694
Country	:	US
Telephone Number	:	605-718-5500
Fax Number	:	605-716-0415

Provider Business Practice Location Address
First Line	:	636 SAINT ANNE ST
Second Line	:	SUITE 202
City	:	RAPID CITY
State	:	SD
Zip	:	57701-4694
Country	:	US
Telephone Number	:	605-718-5500
Fax Number	:	605-716-9944

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	06/03/2021

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